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NOTES 



OF 



LECTURES 



THEORY AND PRACTICE OF MEDICINE, 



DELIVERED IN THE 



JEFFERSON MEDICAL COLLEGE, 



PHILADELPHIA. 



SECOND EDITION, CORRECTED. 



BY JOHN EBERLE, ML. D. 



CINCINNATI: 

PUBLISHED BY COREY & FaiRBANK, 200, MAIN STREET. 

7834 

t 



^v 1 






fc 5 






EASTERN DISTRICT OF PENNSYLrAJYIA, to wit: 

BE IT REMEMBERED, That on the twelfth dav of October, 

(L. S. ) in the fifty-second year of the Independence of the United States of 

America, A, D/1827, John Eberle, M. D. of the said District, 

hath deposited in diis Office the Title of a Book, the right whereof he claims as 

author, in the words foUo.ving, to wit: 

"Notes of Lectures on the Theory and Practice of Medicine: 
"delivered in the Jefferson Medical College, at Philadelphia. 
"By John Eberle, M. D." 

In conformity to the Act of Congress of the United States, entitled, "An 
Act for the encouragement of learning, by securing the copies of maps, charts, 
and books, to the authors and proprietors of such copies, during the times therein 
mentioned." And also to the Act, entitled, "An Act supplementary to an 
Act, entitled, 'An Act for the encouragement of learning, by securing the co- 
pies of map?, charts, and books, to the authors and proprietors of such copies, 
during the times therein mentioned,' and exiending the benefits thereof to the 
arts of designing, engraving, and etching, historical and other prints," 

D. CALDWELL, 

Clerk of the Eastern District of Tenniylvani*. 




PREFACE. 

This little work is published expressly for the use 
of the students attending the author's lectures on the 
Theory and Practice of Medicine. It embraces 
little more than the main propositions and facts, 
which form the ground-work of the lectures; in 
other words,- — the text upon which he enlarges and 
comments in extemporary discourse; and which, 
especially, the student ought to impress upon his 
memory. The practice of taking notes, though at- 
tended with some advantages, is nevertheless, on 
the whole, calculated to lessen the benefits to be 
derived from oral instruction. The train of thought 
and reasoning is interrupted ; and the mind irregu- 
larly hurried along the current of the speaker's ob- 
servations — seizing somtimes upon remarks that are 
comparatively unimportant, at the expense of others 
of a more useful and interesting import; and losing 
in a great measure the general spirit and scope of 
the speaker's discourse, — more especially when the 
subject is one of general disquisition. These dis- 
advantages, it is believed, will be diminished, if not 
wholly obviated, by works constructed on the plan 
of the present one. Being secure of the text, or pro- 
positions, the student may yield his mind, without 
embarrassment, to the explications and discussions 
of the lecturer. His efforts, too, in recalling to his 
mind the observations he mav have heard from the 



Vi PREFACE. „ 

speaker, will be greatly favored,* by looking c 
in private, the sketch which is thus placed in 
hands. 

The author acknowledges, that this manual does 
not come up to the idea he has formed, of the pro- 
per construction of a text book of this kind ; but* 
such as it is, he flatters himself, -that it will in some 
degree answer the intentions for which it was com- 
posed; and with this hope, he respectfully dedi- 
cates it to those students of medicine, who do him 
the honor of attending his lectures. 



TABLE OF CONTENTS. 



Anasarca, 




185 


Angina pectoris, 


- 


183 


Arachnitis, or Hydrocepalus acutus, 


- 


66 


Ascites, - 


- 


186 


Asthma, - 


- 


180 


Bronchitis, acute, - 


- 


89 


■= chronic, 


- 


90 


Cholera, 




192 


Chorea, - 


. - 


170 


Cold, 


- 


11 


Colic, flatulent, - 


- 


193 


bilious, 


- 


194 


Colica pictonem, - 




196 


Critical days, 




26 


Croup, spasmodic, 


- 


91 


Cynanche tonsillaris, 


- 


93 


Cynanche trachealis, 


- 


90 


Cystitis, 


- 


104 


Diabetes, - 


- 


107 


Diagnosis, general, 


- 


13 


Diarrhoea, - 


- 


190 


Dropsy, - • 


- 


184 


Dysentery, - 


- 


79 


Enteritis, acute, 


- 


77 


chronic, 


- 


83 


Epilepsy, 


- 


162 


Epistaxis, - 


- 


138 


Erethism of the brain, 


- 


70 


Erysipelas, - 


-- 


132 


Exanthemata — Small pox, 


- 


116 


Fever in general, and causes of, 


- 


9 


, its general course, 


- 


29 


, Intermitting, 


- 


33 


•, Remitting, 


- 


40 


-, Yellow, 


- 


44 


-, Inflammatory, 


- 


47 


, Typhus, 


- 


52 


■, Catarrhal, 




51 


Fevers, Type of, 


" 


29 



Vlll CONTENTS. 

Gastritis, acute, - - . "72 

chronic, - 74 

Gout, - - - - -111 

Hsematemesis, - 139 

Hematuria, - 141 

Hasmoptisis, - 143 

Haemorrhois — Piles, - - 11 

Hasmorrhagiaa, - 137 

Hemiplegia?, - - - - 157 

chronic, - - - 101 

Hepatitis, acute, - 99 

Hydrothorax, - - - - 187 

Icterus — Jaundice, - 205 

Indigestion, ----- 201 

Inflammation in general, - 60 

chronic, - - - 65 

of Brain, - - - ib. 

Mental diseases — Mania, - - - 211 

Neuroses — Apoplexy, - 153 

Nephritis, ... - 103 

Paralysis, - - - - - 157 

Paraplegia, - 158 

Parotitis, - - - - - 94 

Paralysis partialis — local palsy, - - 159 

Peripneumony, - - - - 86 

Peritonitis, acute, - 95 

— chronic, - - - - 98 

Pertussis — Whooping cough, - - 176 

Phrenitis, - - - - - 105 

Phtisis pulmonalis, - 145 

Pleuritis, acute, - - - - 85 

chronic, ... 90 

Pneumonia biliosa, - - - - 88 

Prognosis, - " - - - 23 

Pulse, - 19 

Rheumatism, acute, - 105 



chronic, - - - - 109 

Rubeola — Measles, - - - 125 

Scarlatina, - 128 

Scrofula, 208 

Softening of the brain, - - - - 71 

Tetanus, - 172 

Variola, - - - - 116 

Variola vaccina, - - - - 121 

Varioloid, ----- 123 

Varicella — Chicken pox, - - 125 

Verminous affections, - - 214 



NOTES OF LECTURES, 



CHAPTER I. 



OF FEVER IN GENERAL. 

Idiopathic — (seldom.) 
Symptomatic, — dependant on: 

local irritation 

inflamation, 

generally seated in the mucous tissues j — frequently in the 
serous. 

Proximate Cause: 

located in the capillary system of blood vessels. (See 
Practice of Med. Chap. 1.) ^f' 

The morbid actions of the heart and arteriee are mere sym- 
pathetic phenomena, dependent on a primary local irritation 
of a part or the whole of the sanguiferous capillary system. 

The proximate cause consists: 
in a deranged condition of the vital properties of the 

capillary system whence result irregular actions 

from the impression of normal and innormal irritants. 
Remote causes of fever: divided into; 
predisposing and exciting ; 

There exists, however, no essential distinction between the 
predisposing and exciting cause. Every predisposing cause 
may become an exciting cause,by continued or intense action. 

Predisposition consists for the most part in: 
local, and rarely in mere 
general debility. (See Pract Med. p. 28.) 



10 OF FEVER IN GENERAL. 

The origin of all possible cause of fever is quadruple, 

1. Retained recrementitious materials, in consequence of 
the accidental torpor of one or more of the emunc- 
tones. 

2. Substances generated in the system, independent of 
organic actions, worms, acid, &c. 

3. Materials generated out of the body : miasmata, heat, 
cold, &c. &c. 

4. Substances generated by diseased organic actions — 
contagious. (See Pract. of Med. p. 31.) 

General nature of these causes. 

They are irritants: 

Some of them invariably produce the same disease, as 

the contagious. 

Certain distinct febrific causes cannot develop their 

morbid effects at one and the same time in the same 

system : measles and small-pox. 
All morbid agents act primarily on the nervous system. 

Through the lungs and respiratory passages, 

The stomach and intestinal canal, 

The skin, and 

Peri. rne D l°°d. 

Phmnlt;,, It >« highly probable that all aeriform morbific agents act on the 
system through he respiratory organs. Some of them may be 
absorbed into the circulation, and act upon the nervous extre- 
mities of the blood ; others may act directly on the nerves of the 
mucous membrane of the respiratory passages. The former 
mode of acting, is, I presume, generally, if uot always the case. 

The causes of fever are divided into three classes. 

1. Sensible properties of the atmosphere: heat, cold, moi- 
ture, electricity, &c. &c. 

2. Contagious, — the result of organic actions. 

3. Miasmata, — the result of physical changes. 

Heat. Specific temperature of the human body, 98o, 
Most agreeable temperature of surrounding air, 65o. 
Atmospheric heat not a deletereous agent; predisposes 
to the influence of morbific causes ; increases the secre- 
tion of bile ; indirect cause of disease, by favoring the 
generation of miasmata. 



OF FEVER IN GENERAL. 1 1 

Dr. Johnson observes, that solar heat only produces the pre* 
disposition; while terrestrial exhalatious, and vicissitudes of 
temperature, call into action the principal diseases of warm cli* 
mates. (See Pract. Med. p. 39.) 

Cold. No positive existence — a mere relative degree of 
temperature ; lessens the action of the heart and arte- 
ries ; causes a shrinking of the surface of the body ; di- 
minishes sensibility and contractility; produces irresis- 
tible disposition to sleep ; and depresses the moral and 
physical energies of the system, wheu long and intense- 
ley applied. Suddenly or transiently applied, it ex- 
cites the nervous system. In alternation with heat, a 
fertile cause of disease ; the diseases resulting from its 
influence, mostly pneumatic, catarrhal, or rheumatic; 
cold water externally applied, or received into the sto- 
mach when the body is heated and in a free state of 
perspiration, often proves suddenly fatal. Always 
more injurious in its influence, when accompanied by 
moisture. (See Pract. Med. p. 35.) 

Miasmata. Heat and moisture essential to the production 
of miasmata* Moisture need not be abundant; in- 
undated grounds extricate little or no miasmata ; hence 
the rainy seasons of tropical countries are the most 
healthy. Miasmata are seldom generated at a temper- 
ature below 80o ; their precise nature unknown ; there 
is reason to believe, that they consist of particles of pu- 
trid vegetable and animal matter, dissolved in aque- 
ous vapour. Chemical analysis can detect no differ- 
ence between the air of marshes and atmospheric air. 
GasparaVs experiments on putrid matters received 
into the body, support the opinion that marsh mias- 
mata consist of putrid vegetable and animal matter 
suspended in the air. 

Miasmata possesses greater specific gravity than at- 
mospheric air; they are conveyed to a considerable 



*It has lately been contended, that moisture is not essential to the generation of mias- 
mata : but, as I believe, without good grounds. (Ferguson.) 



12 OF FEVER IN GENERAL. 

distance by currents of wind ; the distance at which 
they are capable of infecting, by being thus carried, is 
from two to three miles(Bancroft says, but one fourth 
of a mile;) storms and violent blasts disperse and ren- 
der them innocuous ; more danger in miasmatic atmo- 
sphere at night than during day; most danger about 
the setting or rising of the sun; situations are protec- 
ted from the effects of miasmata, by interposing obsta- 
cles, as houses, walls, wood, hills, &c.; long and gra- 
dual exposure to miasmata, destroys the susceptibility 
of the system to their more violent influence. Per- 
sons unaccustomed to them seldom escape disease, 
when subjected to their action. They produce inter- 
mittents and remittents, of various grades of violence. 
(See Pract. Med. p. 40.) 

Contagion. A deletereous agent, generated by the living 
body in a state of disease. The diseases produced 
by this class of causes, preserve a determined or spe- 
cific character; contagious diseases divided into chro- 
nic and acute; the later seldom affect the same person 
more than once; — the former may affect repeatedly ; in 
the acute, there can be no relapse. Contagious matter 
either a palpable substance, or an imperceptible efflu- 
vium; chronic contagious affections always produced 
by the former, and by actual contact; some acute con- 
tagious diseases communicated both by contact and 
and through the medium of the air; that is, both by a 
palpable virus and an effluvium. Typhus fever, under 
certain circumstances, contagious; appears to be pro- 
pagated by effluvia only. 

Contagious effluvia extend but a short distance, suffi- 
ciently concentrated to produce disease. The experi- 
ments of Dr. O'Ryan make it but a few feet — four or 
five feet; currents of air will convey it much further; 
contagions rendered harmless by diffusion in the air; 
hence the utility of free ventilation; contagion attach- 
es itself to various substances; the substances most 



GENERAL DISEASES. 13 

apt to receive and retain it, are, wool, hair, cotton, 
wood, cloths, &c; contagion influenced by certain 
occult conditions of the atmosphere ; contagious disea- 
ses communicated from the inferior animals to the 
human species. 

Disinfecting means; cleanliness; free ventilation; 
muriatic and nitrous vapors; lime; fumes of sulphur, 
and heat. (See Pract. Med. p. 56.) 



CHAPTER II. 

GENERAL DIAGNOSIS. 



Diagnostic signs divided into those exhibited by the 
countenance; the attitude; the nervous system; the 
dgiestive organs; the circulatory system; the respir- 
atory organs; the circular surface; the lymphatic 
system; the secretions. 

The Countenance. The features to be particularly 
examined, are: the eyes the prolabia; the nostrils; the 
lips; the brows. 

In acute simple fever ; eyes and face red; respiration hur- 
ried ; motions of the nostrils rapid. Tn acute sympa- 
thetic fever, these signs are absent. (Hall.) 

Acute pain, from inflammation in the chest: features 
much contracted ; the alee nasi acute and elevated, the 
nostrils contracted and expanded by the acts of respi- 
ration, sometimes a vivid flush terminating abruptly — 
heat inconsiderable. 

Dull pain in the chest: less constriction of the features; 



14 GENERAL DIAGNOSIS. 

an expression of great anxiety ; nostrils widely dilated 
before inspiration. 

Effusion into the lungs: countenance livid, anxious, tur- 
gid, with great dyspnoea, and dilation of the nostrils on 
inspiration. 

The phtJiisical countenance. 

Acute pain in the abdominal viscera; features acute; 
forehead wrinkled ; brows knit ; nostrils drawn up and 
acute; under lip drawn down, exposing the teeth. 

Organic affections of the heart: countenance anxious ; 
vividly flushed; prolabia livid : face turgid, cedematous. 
cold. In hydrothorax, the face has a pale-livid aspect, 

Soporose affections: flushed, livid, tumid, eyes closed or 
open and fixed, mouth frequently drawn to one side. 

In syncope: pale, shrunk, cold, and death-like. 

In chlorosis: pale, exsangueous; icterode; puffy; a pe- 
culiar darkness occupying the eyelids, and extending 
towards the temples and cheeks, and sometimes sur- 
rounding the mouth. 

Distinction between the icterode appearance, and the dif- 
ferent shades of icterus, (Hall) the yellowish tinge in 
in the latter is particularly seen in the albuginia of the 
eyes; in the former, the eyes remain untinged. The 
tinge of icterus depends on bile; that called icterode, 
on a morbid action of the cutaneous capillaries. (Hall.) 

Chronic irritation of the bowels: puffy countenance; 
upper lip pale and swollen ; occurs in verminous affec- 
tions and in scrofula. 

Attitude. The healthy attitude: 

Advantages to be obtained from position, in the treat- 
ment of diseases. 

Preternatural determination to a part, diminished by ele- 
vating such part: the head to be raised, in apoplexy; 
the extremeties, when affected with inflammation. 

Supine position, with tremulous motion, indicates much 
muscular debilty. 



GENERAL DIAGNOSIS. 15 

Fever from acute local inflammation; not attended with 
• with muscular prostration. 

Characteristic position in hydrolhorax : in slight cases, 
head and shoulders elevated when in bed ; in severe 
cases, inability to lie down. The erect position more 
urgent, when complicated with organic affection of the 
heart. When sitting up, hands forcibly pressed on the 
chair on which the patient sits ; or leaning back, with 
the arms and hands placed behind the back. (Hall.) 

Thoracic effusion, distinguished from mere organic dis- 
ease of the heart and lungs, by the effects of firm pres- 
sure on the epigastric region, and bodily exertion. 
Effects of pressure, in effusion : general agitation, cough 
and a sense of suffocation ; not so, or but slightly, in or- 
ganic affections of the heart and lungs; bodily exertion 
excites more dyspnoea, and distress in effusion, than in 
organic affections . 

Position assumed by the patient, in abdominal inflam- 
mation, with acute pain: fixed, carefully avoiding all 
motion and pressure; generally on the back, knees 
drawn up, and head and shoulders a little elevated. 

Position assumed in spasmodic pains of the abdomen. 
constantly changing posture, desirous of pressure on 
the abdomen, recumbent on the belly, &,c. 

Position on the back, with knees constantly elevated, in 
the latter stage of acute diseases, a sign of retention of 
urine. 

The Tongue. Attention to be paid to its colour, its sur- 
face, its shape, and the manner in which it is protruded, 

A white and slightly loaded tongue, indicative of slight 
gastric derangement and moderate febrile excitement. 

A clean, deep red, smooth tongue, indicates inflammation 
or high irritation of the mucous membrane of the sto- 
mach and intestinal canal. 

Tongue seldom much affected in acute symptomatic fe- 
vers, from wounds or external inflammations. 



16 GENERAL DIAGNOSIS. 

Florid papillae protruding through a layer of white fur, 
characteristic of scarlatina. (Hall.) 

Diagnosis, from the appearance of the tongue, between 
phthisis, and hectic with cough, from hepatic and gas- 
tric affections: tongue natural in the former; covered 
with brown fur in the latter. 

A pale and tumid tongue, with large papillae, indicative 
of gastric debility — met with in chlorosis. 

A contracted and pointed tongue, frequently an attendant 
on cerebral or meningeal inflammation. 

A flabby and dilated tongue occurs in congestive states of 
fever. (Miner.) 

A yellow and bitter tongue, indicative of biliary derange- 
ment. 

Morbid^States of the Nervous System. 

Disturbed Sleep. Coma always denotes oppression of 

the brain, 
Wakefulness, a sign of great irritation or exhaustion. 
Sudden starting in sleep — intestinal irritation from 

worms, &c. 
Hurried wakings, with a horrific sense of suffocation, a 

sign of organic diseases of the heart. 
Strabismus, double-vision, signs of cerebral affection. 
Torpor of the sense of touch. 
Morbid sensations. 

In strumous disease of the mesentary, an unusual sensibility to 
cold constitutes a peculiar and very early symptom. (Hall.) 

Pain may arise from inflammation, from spasm, and 

from nervous irritation. They have each their peculiar 

character. 

Inflammatory pain: tenderness of the part, increased 
by pressure ; throbbing or burning continuous, and at- 
tended by febrile excitement. 

Spasmodic pain: paroxysmal, not throbbing, nor bur- 
ning, relieved by pressure, and seldom attended with 
fever. 



GENERAL DIAGNOSIS. 



17 



Neuralgic pain: transient but violent paroxysms, darting 
along the nerves with the rapidity of lightning ; no swel- 
ling, no heat, and readily renewed by the slightest touch. 

Inflammatory pain, modified by the nature of the struc- 
ture in which the inflammation exists. Diagnastic in- 
ferences. Pain referred to parts remote from that in 
which the primary affection resides. 

Alimentary Canal. 

Nature and appearances of the alvine discharges. 

Clay-coloured fseces indicate deficiency of bile — met 
with in jaundice. Diagnosis between infantile remit- 
tent and hydrocephalus — the alvine discharges in the 
former are dark brown, or mud- like, and very fceted — 
in the latter, glairy darh-green, like chopped spinage. 
(Cheyne.) 

Watery and reddish stools, like the washings of flesh. 

Mucous and bloody stools. 

Respiratory Organs. Accelerated respiration always 
attended with frequency of the pulse. Irregular and 
unequal respiration indicates cerebral oppression ; — 
slow, irregular, and sterterous breathing, attends a high 
degree of cerebral compression. 

Abdominal respiration, indicates pneumonic inflamma- 
tion. 

Breathing with the intercostal muscles, without the ac- 
cessory action of the abdominal muscles, indicates ab- 
dominal inflammation. 

Peculiar respiration inhydrothorax: inspiration quick, and 
with great effort; respiration slower, without effort. 
(Hall.; 

The effects of corporeal exertion on respiration: produ- 
ces great dyspnoea in hydrothorax, and still more in 
organic cardial affections. 

Wheezing respiration — in asthma, cynanche trachealis. 
Hurried, panting, and heaving respiration, with sighing, 



18 GENERAL DIAGNOSIS. 

often attends intestinal irritation and exhaustion from 
haemorrhage. (Hall.) 

Cough. When the efforts of coughing are anxiously re- 
pressed^ there is probably inflammation in the chest or 
abdomen. 

Spasmodic cough — in pertussis — sometimes from irrita- 
tion of the stomach. 

Sputa. White cream-like, in chronic bronchitis: 
Effects of full inspiration and expiration, as a diagnostic* 

Cuticular Surface. Its temperature; its colour; its 
state of dryness or moisture ; its fulness or construc- 
tion ; its roughness or smoothness. 

A yellowish tinge indicates biliary derangement ; not to 
be confounded with the sallowness which occurs in 
cancer and chlorosis. 

A purple or bluish colour occurs in infants, from pervi- 
ous foramen ovale. 

Dark coloured or purple spots, — extravasations of blood. 

A pale, semi-transparent skin, particularly of the pro- 
labia and face, manifests paucity, or very serous, blood 
— after profuse bleedings and from anaemia. 

Cold skin, with a feeling of internal heat, denotes inter- 
nal congestions. 

Color mordax — in typhus. 

Permanently dry and husky skin, indicates torpor or 
chronic disease of the liver. 

Urine. Small in quantity, and red in inflammatory affec- 
tions; copious and limpid in nervous diseases. 

Bilious urine. 

The various sediments — lithates; phosphates; the former 
are red or purple — the latter, white or pale yellow. 



See Dr. Hall's work on Diagnosis. 



THE PULSE. 



CHAPTER III. 



THE PULSE. 



19 



The pulse varies with the age of individuals; at birth, 
it beats from 130 to 140 in a minute: mean rate for the 
first month, is 120; limits during the first year, are 106 to 
120; for the second year, from 90 to 100, for the third, 
from 80 to 90 — nearly the same for the fourth, fifth, and 
sixth years; in the seventh year, pulse about 78; from the 
twelfth year, it differs but little from that of adult age, 
which is estimated at from 60 to 80, according to indivi- 
dual constitutions, &,c. (Heberden.) The common stan- 
dard of frequency may be placed at from 70 to 75 beats 
in a minute. (Falconer.) From the 45th to the 60th year, 
the pulse gradually becomes slower; after this period, it 
again rises in frequency. (Floyer.) Generally more fre- 
quent in women than in men. (Falconer.) Climate influ- 
ences pulse; more frequent in hot than in cold countries. 
The time of day: slower in the morning than at other 
times ; most frequent soon after dinner ; slower during 
sleep than in the waking state. Bodily exercise accele- 
rates the pulse; varies according to the 'position of the 
body ; slowest while lying down ; slower when sitting than 
when standing. (Dr. Robinson.) Mental excitement influ- 
ences the pulse ; joy, and anger, render it fuller and more 
frequent; grief, sorrow, and fear, depress it. 
Mode of examining the pidse. (Celsus, Rush.) Not to 
be examined immediately on entering the patient's 
room ; — the examination to be repeated at short inter- 
vals; should be felt in both wrists, the arm having its 
muscles relaxed by proper positions ; two or three fin- 
gers to be applied to the artery ; thirty or forty pulsa- 



20 



THE PULSE. 



tions are to be felt at each examination; examined in 
different positions of* the body: talking must be for- 
bidden. 

Pathological Condition or the Pulse; considered 
in 'relation : 

1. To the force of the pulsations. 

2. To the rythm or mode of the pulsations. 

The most prominent and useful pathological states 
of the pulse, consist in -.frequency, quickness, strength, 
fullness, hardness, and irregularity. 

A frequent Pulse is one in which the pulsations 
succeed each other with preternatural rapidity; a pulse 
beating more than 1(>0 in a minute, is scarcely to be 
counted; great frequency of pulse always connected 
with great prostration of the vital energies ; frequency, 
with fulness and strength of pulse, more dangerous 
than the same degree oi frequency, with softness and 
moderate fulness. When it rises above 120, in in 
flammatoryjjfevers, much danger is to be apprehended, 
(Heberden.) 

Slow Pulse: occurs from cerebral compression,- — 
internal venous congestions, and impairment of the 
vital energies ; as in apoplexy, congestive fevers, and 
malignant fevers. 

Quickness of pui.se: often confounded, improperly, 
with frequency. Quickness refers to the suddenness 
with which each individual pulsation is made— fre- 
quency has reference to the number of pulsations in a 
given time. Quickness, however, is generally atten- 
ded by frequency. 

A strong Pulse is one which gives the sensation 
of preternatural resistance to the finger, during the di- 
astole; not4o be confounded with a hard pulse. It is 
hard, when the artery is felt firm under the finger like 
a tense cord, both in its systole and diastole — some- 
times called corded. Strength and great frequency 



THE PULSE. 21 

never united, a strong pulse seldom exceeding 115 beats 
in a minute; a strong pulse indicates energy of the vi- 
tal powers, and is therefore favorable. 

A feeble Pulse, the reverse of a strong pulse : it 
is feeble, when the artery produces a weak impulse 
against the finger, during its diastole. Feebleness and 
softness of pulse, not synonymous — the artery may re- 
sist pressure, and yet pulsate very feebly. The pulse 
is sojt, when the artery appears to be filled, and yet 
offers no resistance, vanishing by slight pressure. 

A very soft Pulse seldom attended with great 
frequency, or with irregularity; occurring in the ad- 
vanced stages of fevers, favourable, when joined with 
great difficulty of respiration, and suffused countenance, 
in pneumonic inflammation, indicative of much danger. 

Full Pulse. Never very frequent; sometimes 
much slower than natural. 

Small Pulse — the diameter of the artery is smal- 
ler than natural ; in inflammations seated above the di- 
aphragm, the pulse is generally full — when seated below 
it is small. (Borden.) 

Depressed Pulse: small, and apparently feeble, and 
occasionally quick, does not depend on actual debility 
or exhaustion, but on internal venous congestion. — 
Blood-letting will raise this pulse ; distinguished from a 
small and weak pulse — by attending to the prevailing 
diathesis, — by suffering a few ounces of blood to flow, 
and watching its effects, — and by observing the period 
of the disease in which it occurs ; if it is small and ob- 
scure in the beginning of acute diseases, we may "pre- 
sume it is depressed. 

Intermittent Pulse: when not attended by other 
alarming symptoms, not in general a dangerous sign j 
pulse sometimes habitually intermits; it is said to be 
of dyspeptic origin ; occurs frequently in old age, and 
then probably depends commonly on some affection of 
the heart ; occurs also in affections of the brain ; a very 



22 THE PULSE. 

unfavorable sign, in the advanced stage of fevers, with 
great prostration ; is said frequently to precede a criti- 
cal diarhcea. (Senac, Solano, Coxe.) 
Unequal Pulse: synonymous with irregular pulse. — 
Characterized by a constant variation of the pulsations, 
in frequency, quickness, size, hardness, &,c. More 
dangerous than an intermittent pulse. Dicrotus pulse, 
twice-beating. 

Gaseous Pulse : tumid — inflated — soap-bubble: al- 
ways indicates much prostration. 

Undulating Pulse: a wave-like rising and falling 
of the pulse; generally large, soft, and feeble. When 
very small, it is termed creeping; highly dangerous. 

A morbidly natural Pulse: occurs in malignant 
fevers; exceedingly unfavourable; can only be distin- 
guished from a healthy pulse by the concomitant symp- 
toms. 

Shattered Pulse: pulse feels like a shattered quill 
under the finger — occurs in opium eaters. 

Obstructed Pulse: artery remains equally full du- 
ring its diastole and systole. 

The Compound Pulses The principal are the syno- 
cha; synochus; synocliula; typhoid !y and typhus. 

1. Synocha: hard, full, frequent, and strong; indi- 
cates high imflammatory excitement 

2. Synochus : full, round, active, but not hard: oc- 
curs in the hot stage of intermittents ; in remit- 
tents, &c. 

3. Synochula: quick, tense, small, hard, vibrating: 
occurs in sub-acute rheumatism — inflammation 
of the intestines, peritoneum, &,c. It is the hec- 
tic pidse. 

■4. Typhoid: quick, small, slightly tense, not hard, 
and somewhat frequent: in the advanced sta- 
ges of billious fevers — the result of irritation in 
an exhausted state of the system. 



GENERAL PROGNOSIS. 23 

5. Typhus: small, very frequent, somewhat quick: 
occurs in the advanced stages of jail, hospital, and 
other varieties of typhoid fevers. 



CHAPTER IV. 



GENERAL PROGNOSIS. 



The evidence of a single symptom not sufficient to 
give a decisive prognosis ; the cause, the concomitant phe- 
nomena, the temperament and habits of the patient, &c. 
must be carefully estimated. 

The Countenance. The more it varies from its natural 
expression, the more unfavourable. Hippovratic coun- 
tenance — nose pointed, eyes sunk, temples hollow, 
ears cold and shrivelled, the lobes everted ; skin on the 
forehead hard, tense, and dry, countenance pale, livid, 
or leaden: a fatal symptom, in the last stage of acute 
diseases. One eye becoming smaller than the other, 
a bad sign; still worse (Stoll) when objects appear 
less to one eye; lividity of eyelids, lips, and aim nasi f 
unless in chills, very unfavorable;- pointed nose, and 
much motion of the nostrils during inspiration, bad. 
Attitude. Constant position on the back, and sliding to- 
wards the foot of the bed, unfavourable; it betokens 
great prostration: same position, with open mouth, di- 
lated pupils, or involuntary discharges, still worse. In- 
sensibility, with mouth firmly closed and eyes fixed, a 
forerunner of convulsions ; great desire to sit up, with: 
dyspnoea, and livid countenance, fatal in pneumonia 
diseases; still more certainly fatal, when attended with 



*24 GENERAL PROGNOSIS. 

a good pulse. (Baglivi.) Most favorable posture, 
that which approaches nearest to health ; reaching into 
the air, and picking the bed-clothes, bad ; always unfa- 
vorable, when visceral inflammations supervene to 
simple fevers ; tumefaction of the abdomen, and tender- 
ness to pressure indicate danger; laborious breathing, 
with short, irregular, and interrupted acts of inspira- 
tion, is a bad sign; a still more dangerous sign, is ex- 
clusive abdominal respiration, attended with strong mo- 
tion of the alee nasi by the respiratory act ; sterterous 
breathing, attended with a rattling in the upper part of 
the chest, is highly dangerous, though not invariably a 
fatal sign ; short and very accelerated breathing, al- 
ways a bad sign; free and easy respiration, favoura- 
ble ; hiccough, in the advanced stages of fevers, indi- 
cates danger. 

Constant wakefulness, or somnolency, is unfavourable — 
when great pain in the head, pulsation of the carotids, 
and a puffed red countenance attend ih^ latter, there is 
much danger. Unequal distribution of temperature — 
a sensp.tion of cold externally, and of heat internally, 
are bad signs ; — still more unfavorable, when a sense 
of burning heat on the surface is attended by a feeling 
of cold internally. 

Intellectual and moral habits. When these are chan- 
ged; when old associations are interrupted; new anti- 
pathies formed ; when the moral become profane and 
loose in their language, it is a dangerous sign. 

Partial insensibility of the sensorial functions, more 

favorable tli an great acuteness in this respect. Into- 
lerance of light, with involuntary flow of tears, filmy, 
protruded, or very sunken eyes, very bad. 

The excretions. Urine: black, chocolate-coloured, fe- 
tid — or watery and fetid, highly unfavorable; a good 
sign, when after having been crude and watery, it de- 
posites a reddish sediment-still more favorable, when 
attended with a moist skin, of natural warmth. Sup- 



GENERAL PROGNOSIS. 25 

pression of urine, in protracted and violent cases of fe- 
ver, a very bad sign. 

Perspiration: when general, with no very low or high 
temperature of the skin, favorable ; profuse and cold 
sweats, about the head, face, and on the arms and legs, 
highly dangerous ; partial sweat, appearing in large 
drops, a bad sign; profuse, clammy and cold, always 
dangerous; and when attended with a very small and 
frequent pulse, fatal. 

A vine discharges: very liquid, frothy, green-bad signs; 
watery reddish discharges, resembling the washing 
of flesh, and attended with tympanitic swelling of the 
abdomen, a most unfavorable sign. The expulsion 
of wind with crepitus, a good sign. (Rush.) Bloody 
stools without tenesmus, in the latter periods of bilious, 
malignant, or other violent typhoid fevers, highly un- 
favorable; less dangerous in strictly inflammatory 
fevers. Involuntary discharge of faeces, among the 
most unfavorable signs. 

Vomiting. Black flocculent discharges, from the sto- 
mach, exceedingly dangerous;— less dangerous, when 
the black or porracous matter is not flocculent but 
uniformly mixed with the other fluids thrown up. A 
rumbling noise in the stomach, when liquids are swal- 
lowed, a bad sign — never occurs in the early periods 
of fever, and generally attended with meteorism. Sud- 
den and very forcible ejection from the stomach is un- 
favorable — it occurs in yellow fever. (Rush.) Very 
frequent vomiting, with great tenderness in the epigas- 
trium, in fevers, a very unfavorable sign. 

The tongue: covered with a brown or black crust, with 
deep cracks in it, dangerous ; black and dry, with black 
sordes adhering to the teeth, highly unfavorable; a 
dark brown, contracted, hard, and shrivelled tongue, 
almost always fatal; tongue soft, moist, and light red, 
favorable ; secretion of saliva, a good sign ; difficulty 
of putting out the tongue, and then keeping it between 
the teeth a long time, without retracting it, is a bad 



26 GENERAL PROGNOSIS. 

sign — a total inability to protrude it, alike unfavora- 
ble; a red, smooth, and shining, or a pointed, dry and 
red (round the edges) tongue, indicates considerable 
danger — it is a sign of strong gastro-enteritic inflam- 
mation. Total absence of thirst, with a dry and rough 
tongue, is a bad symptom. 

Besides the appearance enumerated above, a variet)' of other 
circumstances demand attention, in forming an opinion as to 
the probable event of diseases. Thus, inflammatory fevers 
are generally less dangerous than remitting fevers; and these 
latter, less dangerous than typhus and malignant fevers. In 
general, the more a fever is connected with local inflamma- 
tions — or rather, the more serious the local inflammations 
are, from the importance of the parts they attack, the more 
danger is to be apprehended. The type, too, must be taken 
into view. As a general rule, intermittents are less danger- 
ous than remittents, and remittents less than continued fe- 
vers. The more irregular the type of typical fevers, the 
more unfavorable. The appearance and progress of what 
are termed the crises will also aid in forming a prog- 
nosis. Unusual or contradictory phenomena are unfavorable; 
when a patient declares himself well, at the same time that 
the symptoms indicate considerable disease, it is a bad sign. 

CRISIS CRITICAL DAYS. 

The ancients observed certain regular periods in the 
course of many febrile diseases, at which prominent 
changes are wont to occur, accompanied by certain 
evacuations, and followed generally by temporary or 
permanent abatement of the symptoms. These eva- 
cutions, and their associated phenomena, are termed : 
Crises. No febrile or noxious matter, as was once 
supposed, thrown off by these critical evacuations. 
Critical discharges theeffect,not the cause of the me- 
lioration of disease which follows, or attends their 
occurrence. The doctrine of critical days gener- 
ally discredited at present; there is probably good 
foundation for the doctrine. Crises divided into 
simple and compound; in the simple, the evacua- 
tion is made through one emunctory only — in the 
compound, through several. The most prominent 
precursory phenomena (perliirbalioncs critica) of 



GENERAL PROGNOSIS. 27 

crises are : an increase of all the symptoms — watch- 
fulness, chills, and rigors —tremor of the whole body 
— anxiety and jactitation — quick and irregular re- 
spiration — obtuseness of hearing — vertigo — coma, 
&c. There are certain days in the course of fevers 
upon which crises are particularly apt to occur. 
These are the critical days; crises occur however 
occasionally on other days. The critical days, ac- 
cording to Hippocrates, are the 3d, 5th, 7th, 9th, 
11th, 14th, 17th, 21st, 27th, and 34th. According 
to Cullen, the 20th, not the 21st day, is the critical 
day — he acknowledges no critical day beyond the 
20th. Critical days divided into perfect, second- 
ary, and intercurrent. Galen regarded the 7th, 
14th, 21st, 28th, or the septenary periods as the true 
critical days;— the secondary, are the intermediate 
days between these septenary periods, i. e. the 4th, 
1 1 th, 18th, 25th, &c. The intercurrent days are 
the 5th, 9th, 13th. (Galen.) 

All forms of fever appear to have a tendency to some one of 
the principal types. A single tertian may be regarded as fe- 
ver in its elementary form. In this form a paroxysm and 
crisis occur on every odd day. Now if we consider a conti- 
nued fever as made up of tertian paroxysms, protracted and 
running into each other, we perceive from its tendency to the 
original type, how the phenomena of crisis should occur on the 
odd days. 

Salutary may be distinguished from insalutary dischar- 
ges by the following circumstances. 

To be salutary, they must be neither too copious, nor too 
scanty; they must correspond with the nature of the fe- 
ver, — haemorrhage is most salutary in inflammatory, 
and diarrhoea, in bilious fevers — perspiration is more 
beneficial in catarrhal fevers than diarhcea. A dis- 
charge from one emunctory only, seldom beneficial ; 
perspiration is never salutary unless the urine at the 
same time becomes charged with a sedimentous matter; 
and vice versa. 



'28 GENERAL PROGNOSIS. 

The evacuations (critical) which usually attend the com- 
mencement of convalescence, are: 

Critical hemorrhages : generally preceded by increase 
of arterial action ; and salutary, partly from the loss of 
the blood, and chiefly by the new arterial excitement 
by which they are attended. 

It is owing to the previous excitement of the arterial system, 
essential to this kind of critical evacuation, that it cannot be 
substituted by an artificial abstraction of blood. This fact 
proves, that such evacuations do not, strictly speaking, pro- 
duce the amendment which follows, but that they are effects 
or manifestations, of a previous salutary change in the vital 
actions. 

Crisis by haemorrhage is chiefly confined to inflammatory 
fevers; occurs sometimes in typhus fevers; epistaxis, 
the most common critical haemorrhage — usually pre- 
ceded by flushed face, red and suffused eyes — sneezing, 
ringing in the ears, &c. 

Critical sweat. The most common crisis ; must be gene- 
ral over the body, attended with a warm skin and 
turbid urine. Its approach indicated by: a soft, full, 
wave-like pulse; a stinging, or itching sensation on the 
surface, red, warm skin and scanty urine. 

Critical discharge of urine: must be copious ; the morn- 
ing urine best for inspection; critical urine exhibits at 
first, a cloud, floating in the upper part of the vessel — 
then a globular body about the middle — and finally a 
sediment; (Vogel, Richter, &c.) should be attended 
with a soft or moist skin; preceded by pains in the 
loins; frequent inclination to urinate; uneasy or burn- 
ing sensation in the genital organs, dry, harsh skin; 
thirst, and a soft and active pulse. 

Critical almne discharges: most frequent in bilious fe- 
vers — occur during the remission of fevers — are copi- 
ous ; signs of approach, a peculiar trembling of the 
under lip — stammering — a full, active pulse, pain and 
noise in the bowels ; discharge of wind — moist tongue 
—paucity of urine. (Richter.) Critical emesis, very 
uncommon. 



GENERAL PROGNOSIS. 29 

By crisis, in the most general acceptation of the term, is un- 
derstood that period in the course of a fever, at which a deter- 
mination either to death or convalescence takes place, and in 
which therefore the fate of the patient is determined. This 
decision must necessarily always occur in the ultimate point 
of violence of the disease. 



CHAPTER V. 



OF THE GENERAL COURSE, TYPE, AND 
STAGES OF FEVER. 



Fevers divided in relation to their course into: 
Acute, and 
Chronic. 
The former generally make their attack suddenly, and 
proceed through their course in a comparatively short 
period . 

The latter commence less violently, and pass slowly 
through their course. 

In general, the more violent the disease, the more ra- 
pid its progress. 

The course of a fever may be divided into five periods. 
(See Pract. Med. p. 61.) 

1. The forming stage — the period between the im- 
pression of the febrific cause and the development 
of the fever; — distinguished by certain phenome- 
na, called premonitory symptoms Its duration 
very various ; not always attended by signs of de- 
viation from health. In general, the more pro- 
tracted the premonitory signs, the more protracted, 
or slow, will be the course of the subsequent fe- 
ver, &c. 



30 GENERAL COURSE, &C OF FEVER. 

It is during the struggle between the system and the morbific 
cause — while the former is gradually yielding to, and passing 
under the dominion of the latter, that the premonitory symp- 
toms occur. 

The most common premonitory symptoms are.- 
loss of appetite: irregular bowels; yawning, 
stretching; mal aise; interruption of ordinary ha- 
bits and appetites, such as disgust for tobacco, 
coffee, <Slc, thirst, nausea, eructations, dry skin, 
slight chills, healing up of old ulcers, &lc. These 
symptoms show that the nervous system, the di- 
gestive organs, and the skin, are the first to suffer 
in the evolution of fever. 

Some diseases have peculiar premonitory symptoms, 
as the measles. A morbific cause may produce 
the premonitory symptoms, without being ade- 
quate to the full development of the disease. 

2. The cold, or second stage: a sensation of cold 
almost invariably introduces a febrile reaction; 
frequently no real subduction of temperature in 
the febrile chill ; it depends therefore often on an 
altered state of sensibility to heat. Symptoms at- 
tending this stage: — skin pale, contracted, dry — 
shrinking of the surface — respiration irregular, 
oppressed, anxious — a small dry cough — tongue 
dry — head confused, pulse small and frequent — 
nausea and vomiting ; the sensation of cold may 
be generally or partially diffused over the body. 
The relation between the violence and duration of 
the stage, to the ensuing stage of reaction, is di- 
rect; the former being violent and short, the reac- 
tion will most probably be vigorous ; weak and pro- 
tracted chills usually followed by feeble reaction. 
A chill occurring in an advanced period of a 
remittent, indicates that it is about altering its type 
or form; occurring in the advanced period of vis- 
ceral inflammations, indicates the occurrence of 
suppuration; crises and metastases sometimes pre- 
ceded by chills. 



GENERAL COURSE, &C. OF FEVER. 31 

Hot, or third stage of fever: characterized by: in- 
creased heat of the skin; return of the natural ful- 
ness and color of the surface ; pulse full, vibrating, 
and vigorous; pain and throbbing in the head; 
eyes prominent, and very sensible to light; a dry 
skin; urine small, and high colored. 

The fourth period, or sweating stage: profuse and 
general perspiration; sedimentous urine; diminu* 
tion of pains in the head, loins, &,c; pulse soft 
and full, &,c. 

The fifth period, or the period of convalescence: 

The course of every fever is either: 

1. Continued: very slight evening exacerbations, 
and morning remissions. Total absence of re- 
missions and exacerbations very rare, if ever. 

Remitting: prominent and regular remissions and 
exacerbations. 

3. Intermitting: regular paroxysms and perfect in- 
termissions. 

One paroxysm, with its intermission, constitutes its 
revolution. According to the duration of the revolu- 
tion, fevers are divided into: 

1. Quotidian, occupying 24 hours. 

2. Tertian, do. 48 do. 

3. Quartan, do. 72 do. 

The form which fevers assume in this respect, is called 
their type. There are therefore three principal types : 
i. e. the quotidian, the tertian, and the quartan types. 
Quotidians generally come on in the morning ; tertians 
about noon ; and quartans in the afternoon. 

Tertians divided into simple and double. 
Double tertians: paroxysms occur daily; but the pa- 
roxysms of the alternate days are similar in violence,, 
time of occurrence, and duration, and differ in these 
respects from those which occur on the intervening; 
days. 



32 GENERAL COURSE, &C. OF FEVER. 

lntermittents rarely are of the double tertian type, from 
their commencement; they generally commence as 
simple tertians, and duplicate their type afterwards ; 
the new or accessory paroxysms generally milder 
than the original; double tertians generally return 
to the simple type, before they terminate; a change 
from the simple to the double type, is unfavorable. 

Other variety of compound types: tertiana duplicata; 
— hcemitritceus ; — tertiana triplex. 

The quartan type is also susceptible of duplication. 
The double quartan has two paroxysms every fourth 
day. Authors mention triple quartans, three parox- 
ysms occurring on every fourth day — these are very 
uncommon. 

The difficulty of arresting the course of an inter- 
mittent, in general, is proportionate to the time occu- 
pied by each paroxysm. 

lntermittents are said to be anticipating, when the 
paroxysm comes on earlier every succeeding recur- 
rence — and postponing, when it occurs later at 
each return. When the paroxysm is postponed to 
about eight o'clock in the evening, it frequently does 
not come on until the next morning. In like man- 
ner, the paroxysm of an anticipating ague, occur- 
ring at eight o'clock in the morning, will have its 
next paroxysm on the evening of the day preceding 
that on which it should happen. ( Wilson.) Favo- 
rable, when the paroxysms are postponed; unfavo- 
rable, when anticipated. 

Attypic, or erratic fevers: no regular type; rheumat- 
ism — catarrhal fever. 
Fevers often change their type — the conversion of type 
seldom suddenly effected. 






INTERMITTING FEVERS. 33 



CHAPTER VI. 



PARTICULAR FEVERS. 



OF INTERMITTING FEVERS 

General Character. A succession of regularly recurring 
febrile paroxysms — commencing with chills, and ter- 
minating in profuse perspiration, with intervals of per- 
fect remission from fever. 

Types: the quotidian, the tertian, the quartan, and com- 
plications of these primary types. 

Stages: the cold, the hot, and the sweating stages. 

Symptoms — Of the cold stage: lassitude, yawning; skin 
pale and shrunk ; pulse small and frequent; rigors more 
or less strong ; mind confused and inattentive^ — when 
violent, comatose ; urine pale and crude ; thirst great ; 
respiration quick and anxious ; lasts from fifteen mi- 
nutes to several hours. 

Hot stage: at first, nausea and bilious vomiting; skin hot 
and dry; face flushed and full ; pulse full, frequent, and 
strong ; respiration free and regular; head-ache — urine 
high colored and scanty. 

Sweating stage: profuse perspiration; pulse soft and mo- 
derately full; urine copious and sedimentous; a gra- 
dual abatement of all the symptoms of the previous 
stage, until it terminates in the state of intermission, or 
apyrexia. 

Anomalous symptoms: the cold stage has been absent; 
sweat sometimes absent in the third stage, being sub- 
stituted by other evacuations. 

Masked Agues, (Fehres Inter mittentes Larvatte.) In- 
tcrmittents under various assumed forms: as epilepsy, 

E 



34 INTERMITTING FEVERS. 

mania, hemicrania, tooth-ache, cramp in the stomach, 
dysentary, cholera, &c. Diagnosis of masked agues : 
their periodioity; the cotemporaneous prevalence of 
intermitting fevers; slight sensations of cold, preceding 
the attacks ; gentle perspiration, with turbid urine at- 
tending their disappearance. (£ee Pract. Med. p. 74.) 
In infants, the paroxysm sometimes commences with con- 
vulsions. Distinct rigors are not common in infants. 
Intermittents divided into the: 

Inflammatory, 

Congestive, 

Gastric, and 

Malignant— (See Pract Med. p. 73.) 

1. Inflammatory Intermittents: of frequent occur- 
rence: quotidians more apt to assume this charac- 
ter than tertians, and tertians than quartans. Oc- 
cur most commonly in young and plethoric sub- 
jects, and in the spring and winter seasons; rigors 
strong in the first, and action intense in the second 
stage ; intermission imperfect, the pulse retaining 
a preternatural quickness and tension, and the 
thirst and heat of the surface remaining greater 
than natural ; often slight pectoral affections. The 
prima via seldom much loaded with bile and 
saburral matter ; little or no manifestation of intes- 
tinal irritation. 

2. The congestive variety : not common; occurs in 
persons of debilitated habits of body — in the irri- 
table and nervous. Cold stage, very protracted, 
attended with deep-seated pain in the head, verti- 
go, syncope, a sense of weight in the breast, coma, 
and a small, trembling, weak, pulse. Hot stage, 
imperfectly developed — the system remaining op- 
pressed; the surface cool; the breathing confined 
and anxious ; countenance pale ; pulse frequent, 
small, and somewhat tense ; and a sense of heat 
internally. (Pract. Med. p. 75. ) 

3. The Gastric variety: the majority of our autum- 



INTERMITTING FEVERS. 35 

nal intermitents are of this character : they are at- 
tended with strong marks of irritating matters in 
the prima vi(B; there is nausea, bilious vomiting, 
bitter taste ; weight and fulness in the epigastrium ; 
great pain in the forehead ; foul tongue ; quivering 
of the under lip ; countenance, and tunica albugi- 
ginia, tinged with yellow ; urgent desire for acid 
drinks. 

4* Malignant Intermittent. Rapid in their course 
— sweat, in the third stage, generally very copious 
and fetid ; hemorrhages from the nose, bowels, 
gums, &,c. * petechia ; and other symptoms denot- 
ing malignity. (Alibert.) 

Intermittents occasionally cure other affections; such 
as cutaneous eruptions, hysteria, gout, asthma, hypo- 
chondriasis, and epilepsy. (Fordyce, Vogel.) 

In relation to the natural duration of intermittents, it 
would appear, that quotidians, when left to themselves, 
have a tendency to terminate on the 14th; tertians on 
the 21st; and quartans about the end of the 6th week. 

Prognosis. When simple intermittents prove fatal, it is 
generally in the cold stage — death then occurs in the 
way of apoplexy; most dangerous in weah and cachec- 
tic habits of body. Postponing more favorable than 
anticipating agues ; scabby eruptions, re-appearance of 
suppressed discharges, &c. favorable ; integrity of the 
digestive functions, a good sign ; change from the quo- 
tidian to the tertian favorable. Delirium more Unfa- 
vorable than mere coma; occurs in the worst forms of 
the disease. Tumid and painful abdomen, with op- 
pressed respiration, hiccough, &c. ; colliquative diar- 
rhoea ; bloody urine, red and suffused eyes — are bad 
signs. Great debility during the intermission, with 
cedem of the legs and feet, restlessness, languor, sigh- 
ing, dry tongue, or bilious vomiting, very unfavorable. 
(Pract. Med. p. 77.) 

Circumstances peculiar to the various types: Cold 



36 INTERMITTING FEVERS. 

stage longer in tertians than in quotidians — hot stage 
longer in the latter than the former; &,c, &,c. 

CAUSES OF INTERMITTENTS, 

The principal — almost exclusive — cause of intermit- 
tents, is marsh miasmata, called by the Italians, ntal aria. 

Intermittents are the first grade of miasmatic fevers — 
most common during the autumnal months, in the marshy 
districts of temperate climates. The operation of mias- 
mata is favored, by sudden changes of weather, damp- 
ness, and whatever debilitates the body. 

Miasmata often remain dormant in the system for a 
long time. 

Other causes : — worms and other irritating substances* 
in the intestines; suppressed habitual discharges, &c. 
(Pract. Med. p. 79.) 

Proximate Cause. 

Spasm of the extreme vessels (Cullen's doctrine) ob- 
jected to. 

Irritation and inflammation of the mucous membrane of 
the intestinal tube, objected to. (Broussais.) (Pract. 
Med. p. 80.) 

TREATMENT. 

Treatment divided into that which is proper during 

the paroxysm, and that which is to be used in 
the intermission. 

The former is palliative, the latter curative. 

Treatment in the paroxysm. Cold stage -.mild and warm 
diluent drinks. In debilitated and nervous subjects, 
external and internal stimulants, particularly artificial 
heat. In vigorous subjects, however, such practice is 
by no means proper. An emetic given in this stage, 
one of the best means to shorten its duration. Opium 
administered just before or soon after the accession of 
the paroxysm, often highly useful in moderating the fit. 
[Trotter.] 



INTERMITTING FEVERS. 37 

Compression by the tourniquet, has been found useful to 
put a stop to this stage. [Kellie.] Its modus operandi 
explained. 

Treatment in the hot stage. The object is to moderate 
the violence of the febrile reaction, and to hasten the 
supervention of the sweating stage. The remedies 
employed for this purpose are : bleeding in cases of vio- 
lent reaction, cool diluent drinks, and the usual anti- 
phlogistic remedies. A draught of cold water, when 
the skin is very dry and hot, is both grateful and bene- 
ficial, predisposing to perspiration. Emetics not pro- 
per in this stage. Excessive vomiting best checked by 
opium and the effervescing draught. Opium highly 
recommended in this stage, by Dr. Lind ; injurious in 
intermittents of a marked phlogistic character ; highly 
useful in cases of feeble reaction. Not often necessary 
to use remediate treatment, in this stage. [Pract. Med. 
p. 32.] 

Treatment during the Intermission. It is in this stage, 
that the radical cure of the disease is to be attempted. 
In prescribing with this view, attention must be paid to 
the four modifications described above. 

In inflammatory intermittents, the febrifuge tonics are 
not to be used, until the phlogistic state of the system 
has been reduced by a strict antiphlogistic treatment. 
(Pract. Med. p. 84.) 

In the congestive and malignant modifications, stimu- 
lants and tonics must be resorted to, early and freely. 
(Pract. Med. p. 75.) 

In Ihe gastric modification, emetics and cathartics are 
important preliminary remedies. 

Cinchona — the most efficacious tonic febrifuge we pos- 
sess — must be employed during the apyrexia. Not to 
be employed, where a phlogistic diathesis prevails — 
that is, where the pulse is tense and quick, with a feel- 
ing of general uneasiness, head-ache, dry and warm 
skin, are present in the intermission ; in such case, anti- 



38 INTERMITTING FEVERS. 

phlogistic measnres must be premised. The bark to 
be promptly and largely given, in cases of great weak- 
ness, or in such as are of a malignant character. Au- 
thors express contradictory opinions, with regard to 
the necessity of purgatives and emetics, as measures 
preparatory to the use of the cinchona. They are very 
generally useful, and should be premised ; not always 
indispensable, however — more essential in the young 
and plethoric, than in the infirm and aged* The cin- 
chona has no peculiar tendency, as was once, and by 
some is still supposed, to produce visceral indurations ; 
these are consequences of the improper use of the 
bark — in other words, of its employment in a promi- 
nent phlogistic state of the system — other tonics will do 
the same. The existence of visceral obstructions form 
an objection to the use of the bark ; a mild mercurial 
course must be premised — or the bark may be given 
in conjunction with mercury. From an ounce to an 
ounce and a half, will in general suffice for a cure — 
when it purges, give opium or kino. When much 
acidity exists in the prima? vise, combine it with an al- 
kali. The bark often advantageously combined with 
aromatics, as serpentaria, cloves, calamus aromaticus, 
black pepper, capsicum, &c. &,c. 

Sulphate of Quinine, a most valuable preparation of 
cinchona ; given in doses of from one to three grains, 
every one or two hours ; sometimes purges, for which 
opium is the proper remedy. A variety of other vege- 
table tonics have been recommended in this disease; 
as Augustura bark, cornus fiorida, Leriodendron 
tulipifera, aristologia serpentaria, oak bark, the 
various species of willow, horse chesnut, and the 
officinal tonic bitters. Coffee, recommended by Rich- 
ter and Grindel . Tela aranearum, a useful remedy. 

The Muriate of Ammonia in combination with tonic 
bitters, highly useful, according to Richter, in agues 
attended with visceral obstructions. 

Arsenic, highly efficacious; best adapted to cases attend- 



^INTERMITTING FEVERS. 39 

ed with rather a full, robust, and unirritable habit, — a 
moderately full, but soft and regular pulse, — and unac- 
companied by local congestions. In debilitated, ca- 
chactic or scorbutic habits, often injurious ; improper 
also in phthisical habits. Should be given in as large 
doses as the stomach will bear ; apt to produce dropsi- 
cal swellings. From ten to fifteen drops of Fowler's 
solution, with ten or fifteen drops of laudanum, every 
four hours. 

Prussiate of iron has been given with considerable suc- 
cess. Dose from five to eight grains every two hours, 
for an adult. 

Sulphate of zinc, an article of very considerable efficacy, 
in the treatment of this disease. In combination with 
capsicum, I have found it almost as certain a remedy 
as the quinine. I give it according to this formula: 
r Sulph. zinci, gr. x. Pulv. capsici, e jj Conserv. rosar. 
q. s. M. in pil. No. xl. dividend. S. one every two hours. 

The power of the imagination over the system, is often 
strikingly illustrated in its effects on this disease ; — the 
source of the occasional efficacy of all the various 
charms, amulets, &c. so frequently resorted to against 
this disease, by the ignorant and superstitious. 

Intermittents exceedingly apt to relapse ; relapses particu- 
larly favored by exposure to a damp and cool air ; by 
errors in diet ; the depressing passions, &,c. 

Intermittents apt to give rise to secondary affections, the 
most common of which are : oedema of the feet ^enlarge- 
ment and induration of the spleen and liver ; jaundice, 
dropsy ;-*- sometimes hemicrania, vertigo, epilepsy, and 
phthsis. See Practice of Med. vol. 1 . 



40 REMITTING FEVER. 



CHAPTER VII. 



REMITTING FEVER. 



Character. Fevers whose symptoms suffer regular exa- 
cerbations and remissions, but no perfect intermis- 
sions. 

Symptoms: Symptoms of the forming stage, similar to 
those of intermittents. When the disease is fully deve- 
loped, there are, pains in the head, back, and lower ex- 
tremeties; an icterode tinge of the eyes; nausea; some- 
times bilious vomiting ; fulness and tension in the prse- 
cordia; pulse full, frequent, and rather soft; tongue foul, 
at first white, afterwards brownish ; taste bitter. In the 
course of about twenty-four hours, a remission of these 
symptoms takes place; after a short remission, the fe- 
brile symptoms rise again; and after a certain period, 
again suffer more or less remission. This answers to 
the mild form of the disease. See Pract, of Med. p. 97. 

The type of remittents is generally the double tertian; 
sometimes the quotidian. The exacerbations of quo- 
tidian remittents commonly begin about nine or ten 
o'clock in the morning ; those of tertians considerably 
later. 

Remittents sometimes assume a very violent and even 
malignant character: the febrile heat is intense; thirst 
excessive; head-ache, and pains in the loins, very vio- 
lent; great anxiety of feeling; distressing sense of ful- 
ness in the epigastrium. In twenty-four hours, nearly 
a complete intermission ensues. A second and more 
violent paroxysm soon corner on ; the eyes become red 
and watery; the epigastric distress is horrible; there is 
nousea, with constant retching or bilious vomiting. An- 
other remission occurs, followed by a third exacerba- 



REMITTING FEVER. 41 

tion, which often terminates in death, or a favorable 
crisis. The disease sometimes assumes more of a 
chronic character ; and in this case, great prostration 
ensues, with almost constant delirium ; a quick, irregu- 
lar, and frequent pulse : in some instances, the pulse 
becomes almost natural — a sign of great danger. Be- 
sides the foregoing symptoms, the following occur, in 
violent cases of this form of fever : tongue clammy, fetid, 
black ; eyes red, watery, or dry j urine brown, blackish, 
offensive — sometimes wholly suppressed; alvine dis- 
charges watery, red, black, or bloody ; abdomen tym- 
panitic, petechia?, haemorrhages. 

In the temperate climates, and in situations not abounding in 
materials for the production of miasmata, remittents are gene- 
rally mild and regular in their course. In proportion as we 
approach the tropical regions, we find the disease assuming a 
more violent and anomalous character. 

Remote Cause. Marsh miasmata the principal cause 
of this form of fever ; other causes may produce it,— 
as worms, and other irritants, acting on the alimentary 
canal. 

Proximate Cause. Irritation, or sub-acute inflamma- 
tion of the mucous membrane of the intestinal tube, 
with prominent hepatic derangement. 

In some cases, prominent intestinal irritation is connected with 
an abundant secretion of bile; in others, the intestinal irrita- 
tion is connected with great congestion and torpor of the liver, 
little or no bile being thrown into the bowels during the early 
period of the disease. To the former class of remittents, we 
may therefore apply the term Gastric ; and to the latter that 
of Hepatic. 

Gastric Modification ; characterized by: bitter or pu- 
trid taste ; tongue covered with a thick yellowish slime, 
which by degrees becomes dry, cracked, and blackish ; 
disgust for every kind of food; urine jumentose; dis- 
tress and weight in the stomach ; abdomen tense and 
tender ; pain in the loins and knees ; intense pain in the 



42 REMITTING FEVER. 

forehead; distinct remissions and exacerbations. — 
Pract of Med. p. 100. 

Hepatic Modification: the most rapid and dangerous 
form of the disease ; characterized by : intense febrile 
heat during the exacerbations ; delirium, fulness, ten- 
sion, and pulsation in the right hypochondrium ; tongue 
at first clean, great irritability of the stomach; conti- 
nued vomiting of a glairy fluid; the skin becomes icte- 
ric; towards the termination of the disease, the liver, 
in most instances, pours out an abundance of dark co- 
lored bile, which is evacuated by stool, and sometimes 
by vomiting. The stools, in such instances, are black 
and pitchy. 

The diathesis of remittents always essentially inflamma- 
tory, though in some violent instances much nervous 
depression and debility exists. Dr. Good calls these 
asthenic remittents, — I prefer the term typhoid. 

Treatment. The indications are: 1. To moderate the 
action of the heart and arteries. 2. To remove the 
irritating contents of the bowels, and moderate intesti- 
nal irritation. 3. To restore the healthy functions of 
the liver. To answer these intentions, we employ: 
1. Bleeding. Not often necessary, in the milder 
cases of our autumnal remittents. Indispensable 
when the pulse is full, vigorous, and hard, the skin 
very hot and dry, and the head-ache intense. 
% Purgatives. Mild mercurial purgatives, of pri- 
mary importance In mild cases, with little gas- 
tric irritability, an emeto-cathartic often useful in 
the commencement ; inadmissable, however, in the 
higher grades of the disease. 

There are no remedies more useful in the treatment of remit- 
tents, than purgatives; and yet there are perhaps no other me- 
dicines sn frequently employed to an injurious extent. Violent 
and irritating cathartics, when frequently administered, sel- 
dom fail to'excite a degree of irritation in the mucous mem- 
of the alimentary canal, which but too often brings on 
:i train of symptoms of the most dangerous and fata! charac- 



REMITTING FEVER. 43 

ier. The thin watery stools, of a muddy or reddish color; the 
tympanitic state of the bowels; the abdominal tenderness; the 
suppression of urine, &c. which are sometimes observed in 
the advanced stages of this disease, are generally the result of 
the imprudent employment of active cathartics. Although I 
would strenuously protest against the frequent employmeut of 
active cathartics during the course of remittiug fever, I would 
by no means proscribe them wholly (as is done by Broussais) 
as remediate means in this form of fever. In the commence- 
ment of the disease, one or two active purgatives are not only 
admissable, but, according to general experience, decidedly 
useful. Subsequently, however, the milder laxatives only 
ought to be employed ; and these are indispensable, throughout 
the whole course of the disease. — See Tract, of Med. p. 108. 

Diaphoretics, &c. Nitre in combination with tartar- 
ized antimony and calomel, generally useful in the 
early stage of mild remittents ; improper where there 
is great irritability of the stomach ; injurious, also, when 
it excites much purging. The saline effervescing 
draught an excellent medicine; spiritus mindereri 
also useful : these two latter articles, particularly useful 
to allay gastric irritability. 

Calomel. An important remedy in remitting fevers. In 
the commencement given with a view both to its pur- 
gative and constitutional effects ; should be early and 
regularly given, until its specific operation becomes ma- 
nifest ; never to be continued until ptyalism comes on ; 
strong mercurial excitement, injurious. In the advanc- 
ed periods of the disease, the mercurial influence gene- 
rally detrimental. 

In the high or malignant grades of this disease — that 
which I have termed Iiepatic, from the engorged and 
inactive state of the hepatic system — emetics, emeto- 
cathartics, and strong purgatives, useful in the com- 
mencement of the milder forms of the disease, are alto- 
gether inadmissible. The first object is to allay gastric 
irritability, which is generally very great. For this pur- 
pose, bloodletting is the most important measure ; sina- 
pisms to the region of the stomach, are good ; a draught 
of cold water has been recommended; the warm bath 
after venesection ; potio Riverii. 



44 YELLOW FEVER. 

When the irritability of the stomach is in some degree 
subdued, Calomel is an important remedy ; it should 
be given in doses of from ten to twenty grains every 
four or five hours, until the evacuations become bilious. 
If the calomel do not prove purgative, mild laxatives 
must be occasionally given with it. Two or three al- 
vine evacuations daily are indispensable, so soon as the 
liver has been excited to action by the calomel. Nitre, 
and the antimonial preparations, are objectionable. 
Acidulated drinks are salutary. Physicians do not 
agree with regard to the propriety of using tonics du- 
ring the remissions. Lind, Clark, Balfour, and others, 
strenuously contend for the vigorous employment of 
bark. Johnson, Burnet, and others, condemn this prac- 
tice as pernicious. Pract, Med. p. 112. 

My own views on this subject are, that the cinchona may be 
used with advantage, during the remission, when there are 
no violent visceral congestions, and where the liver has resum- 
ed its proper action. As long, however, as the liver remains 
engorged and inactive, the employment of the bark can seldom 
fail to do injury. After the bile makes its appearance in the 
alvine evacuations, and a complete remission occurs, the liberal 
use of the sulphate of quinine will generally prove decidadly 
beneficial . 

YELLOW FEVER. 

Synonymes. Typhus Icier odes; Maladie de Slam; 
Bidam Fever; Vomito Prieto; Causes. 

Symptoms. First stage : faintness, giddiness, slight chills ; 
then sudden evolution of intense febrile reaction, with 
severe pain in the head, inflamed eyes; intolerance of 
light; dry and burning skin; great thirst: pain in the 
loins and lower extremeties; tongue covered with a 
whitish mucus, or but little altered from its healthy as- 
pect; nausea and vomiting; transient and partial sweats. 
This stage lasts from twenty-four to sixty hours. 

The disease sometimes commences with sudden loss of muscu- 
lar power, and depression of nervous energy — the patient fall- 
ing down, aa if stunned by a blow. 



YELLOW FEVER. 45 

Second Stage. With the exception of vomiting, all the 
symptoms abate ; the pulse sinks to the natural standard, 
the heat of the skin becomes reduced, and the patient 
expresses himself much relieved. The vomiting how- 
ever continues, the fluid ejected containing membra- 
neous flocculi ; the desire for cold water is urgent, but 
when swallowed, is immediately rejected; the albugi- 
nia, and the skin of the neck and breast, acquire a 
yellow tinge. This stage lasts from twelve to thirty- 
six or forty-eight hours. 

Third stage. Pulse sinks ; frequent and forcible vomit- 
ing; matter thrown up of a black color, resembling 
coffee-grounds suspended in a glairy fluid ; an acrid or 
burning sensation in the stomach; diarrhoea of green 
or black matter ; whole surface of a dirty yellow ; # hae- 
morrhages violent; delirium; hiccough, coma, insensi- 
bility, convulsions, death. 

"Soreness in the oesophagus; heat and acrid sensation in the 
stomach j urgent thirst; hunger; violent delirium; despon- 
dency; enlargement of the blood-vessels and red-yellow color 
of the white of the eye, either singly or collectively, indicate 
extreme danger." (Johnson.) 

Appearances on dissection. A black viscid fluid in the 
stomach ; mucous membrane of this organ inflamed, 
and covered with gangrenous spots ; sometimes large 
portions sphacelated ; small intestines inflamed ; colon 
generally sound, but often contracted ; concave surface 
of liver inflamed. 

Cause. The effluvium generated by animal and vegeta- 
ble matters, in a state of putrefactive decomposition, its 
common remote cause — hence its almost continued 
prevalence in the marshy districts of intertropical 
regions. 

This opinion is disputed by many ; but a great major^ of those 



Many cases are not attended by this yellow hue of the skin. 



46 YELLOW FEVER. 

whose knowledge on this point is derived from personal obser- 
vation, maintain its correctness. (Pract. of Med. p. 118.) 

Europeans arriving in hot climates, where the disease is 
endemic, almost exclusively obnoxious to it. Persons 
having once had the disease, lose in some degree their 
susceptibility to a subsequent attack. 

The influence of the remote cause is promoted by, intem- 
perance, excessive fatigue in the sun ; exposure to the 
damp and cool night air, &c. 

Not contagious* Many assert that under certain circum- 
stances, this disease is not contagious: — some maintain 
its unconditional and essentially contagious character. 

Black Vomit: not bilious matter; — appears to proceed 
from sanguineous transudation in the stomach. The 
liver is torpid and congested, the biliary secretion be- 
ing deficient. The yellow color of the skin is probably 
the result of a vicarious secretion of a bilious matter 
into the subcutaneous texture. Different opinions on 
this subject. Pract. Med. p, 117. 

Treatment. Much diversity of sentiment in relation to 
the treatment of this disease. It appears, however, that 
the weight of good authority is in favor of: fall bleed- 
ing; mercurial purgatives; cold affusions, and applica- 
tions to the head; the free use of mild diaphoretic or 
acidulated drinks — in the first period of the disease. 
Prompt and decisive bleeding is particularly beneficial 
in the commencement of violent cases, where the pulse 
is full and hard. In the milder cases, it may common- 
ly be advantageously omitted. 

In the second stage, mild aperients; diaphoretic and 
cooling drinks; enemata; calomel, with a view to its 
constitutional and aperient effects ; cool affusions, with 
tonics and stimulants, if the pulse becomes feeble. 

In the third stage, stimulants and tonics ; enemata ; mild 
drinks. 

The usual saline diaphoretics are of little or no service, 
in this form of fever. The vigorous employment of 



INFLAMMATORY FEVER. 47 

cinchona, or quinine, is strongly recommended by 
some, during the remissions. 



CHAPTER VIIL 



CONTINUED FEVER. 



Continued fevers are either: 
Sthenic, or 
Asthenic. 

The former are diseases with irritated vascular excite- 
ment — the vital energies being unimpaired or in- 
creased/ these are usually called inflammatory, or fe- 
vers with a phlogistic diathesis. 

The latter are diseases with irritated vascular excite- 
ment, and an impaired state of the vital energies; 
these are the typhous fevers. See Pract. of Med. p. 125. 

INFAMMATORY FEVER 

Synonymes. Arden i fever ; febris irritativa ; synocha ; 
febris vasorum. 

Character. Vascular excitement vigorous; pulse full, 
hard, and strong ; heat of the skin intense ; urine scanty 
and high colored : thirst great ; eyes red, incapable of 
bearing the light ; pulsating pain in the head ; sensorial 
powers little affected. 

This form of fever is seldom introduced by a long train 
of premonitory symptoms ; and in this, it diners essen- 
tially from typhus. The heat of the surface, of the kind 



48 INFLAMMATORY FEVER. 

called hurtling. Delirium not a common symptom. 
The pulse seldom beats more than 110 in a minute. 
The blood, when drawn, separates rapidly into its con- 
stituent parts — the crassamentum contracting into a 
firm mass, on the top of which a yellowish mass of fi- 
brine collects, forming what is termed the buffy coat, 
or inflammatory crust. Pract of Med. p. 129. 

A somewhat similar covering is sometimes formed on the blood 
of typhous patients. The inflammatory buff has a uniformly 
yellowish white appearance. That which is sometimes seen 
on the blood of typhous patients, presents an iridescent ap- 
pearance — reflecting the colors of the rainbow, when held in 
certain positions. It is also much more brittle in its texture, 
than the former. [Richter.] 

Inflammatory fever never very protracted in its course ; 
generally terminates in some manifest critical dis- 
charge ; haemorrhage from the nose, and increased flow 
of sweat the most common. Most apt to occur in per- 
sons of robust and vigorous constitutions, and between 
the ages of twenty and forty. 

Cause. The most common causes are: Atmospheric vi- 
cissitudes ; violent passions ; wounds and other injuries ; 
a peculiar atmospheric constitution. Sudden sup- 
pression of perspiration by cold, is however the most 
common sporadic cause . Hence, inflammatory fevers 
most prevalent in cold and variable climates, or during 
the spring of temperate latitudes ; more prevalent also 
in elevated, dry, and sandy situations, than in localities 
of an opposite character. Pract. of Med. p. 140. 

Diagnosis between sthenic and asthenic fevers some- 
times very difficult. 

The constitution and habits of the patient, the nature of 
the predisposing and exciting causes, will aid us in the 
diagnosis. In very doubtful cases, we must have re- 
course to the indices ex nocentibus et juvantibus — 
the indications drawn from the effects of immediate 
agents. 

Prognosis. Simple inflammatory fe\tr, the least dan- 



INFLAMMATORY FEVER. 49 

gerous variety of continued fevers ; when attended with 
visceral inflammation, dangerous; the danger being 
proportionate to the violence of the local inflammation, 
and the importance of the organ inflamed. When pro- 
tracted, it is apt to assume a typhoid character. A 
sudden and copious discharge of limpid urine, or thin 
watery alvine discharges, are unfavorable Slight 
haemorrhage from the nose, a moist and soft skin, pale 
and turbid urine, are favorable signs. Delirium not 
generally a bad sign* 

Treatment. The principal indications are: to mode- 
rate the action of the heart and arteries, and to restore 
the healthy functions of the cutaneous exhalents. The 
remediate measures are: [Pract. of Med. p, 140.] 

Blood-letting: this is the most important remedy. It 
should be early employed, and to the extent of pro- 
ducing a decided impression on the system. One de- 
cisive bleeding will do more good than double the same 
quantity of blood drawn at several smaller bleedings. 
To produce a proper impression, without too great an 
expenditure of blood, the bleeding should be from a 
large orifice. Repeated small bleedings, during the 
course of a fever, are more apt to prostrate the system, 
than the same quantity of blood drawn at one or two 
bleedings in the beginning. The pulse must be our 
principal guide, as to the quantity and repetition of 
bleeding. The inflammatory character of the blood, 
generally, an indication of the further necessity of 

p~ bleeding. This indication cannot always be relied on 
—it is fallacious in rheumatism, in which the blood 
will often exhibit the buffy coat, after bleeding has been 
carried to the utmost allowable extent. 

Cathartics. Useful not only by evacuating the irritating 
contents of the bowels, but also by their directdeple- 
tory effects. The saline cathartics are the best ; be- 
sides their evacuating effects, they have an antiphlogis- 
tic operation, analogous to nitre. Violent and very 
frequent catharsis, injurious. 

6 



50 INFLAMMATORY FEVER. 

Emetics: seldom proper in inflammatory fevers. 

Diaphoretics are important remedies in this variety of 
fever. Of these, nitre and antimony are the most va- 
luable — they are best given in combination; 10 grains 
of nitre with 1-10 of tart. ant. every hour or two. When 
the bowels -are torpid, a grain or two of calomel may 
be added. Care must however be taken, not to conti- 
nue the calomel so as to produce ptyalism — this effect 
could not fail to do harm. When the nitre excites 
gastric pain and watery purging, a few grains of pulv. 
ipecac, compos, may be advantageously combined with 
it. These effects are also lessened by giving the nitre 
in some mucilage. 

Antimony, peculiarly beneficial in febrile diseases; inde- 
pendent of its diaphoretic effects, it has a direct seda- 
tive operation; it appears, also, to act as an alterative, 
that is, to change the action of the capillary system 
generally. Its good effects in fevers are independent 
of the nausea which it is apt to create. Cullen, how- 
ever, was of a different opinion. The Italians employ 
it in large doses, as a contra-stimulant; in other words 
as a sedative. 

Other diaphoretics employed in sthenic fever, viz. the 
saline effervescing draught; spiritus minderiri ; muriate 
of ammonia; sweet spirits of nitre. These are useful, 
after the febrile excitement has been somewhat sub- 
dued. 

During the whole course, an antiphlogistic regimen must 
be rigidly observed. 

The antiphlogistic plan of treatment consists not only in the 
application of such remedies as are calculated to reduce the 
actions of the system, but also in the careful removal of every 
thing which has a tendency to irritate or excite in an inordi- 
nate degree. In inflammatory fevers, the irritability of the 
nervous and sanguiferous systems is morbidly increased; and 
hence, even the ordinary stimulants of light, sound food, &c. 
become a source of increased irritated action. The influence 
of these must therefore be avoided, as much as circumstances 
will allow. 



CATARRHAL FEVER. 51 



CATARRHAL FEVER. 



Character^ A sthenic fever, with prominent irritation 
of the mucous membrane of the respiratory passages. 

Symptoms. At first, lassitude and slight chills; then 
more or less febrile reaction, — attended with a frequent, 
quick, and somewhat tense pulse ; severe pain in the 
head, face, or jaws ; sneezing, dry cough, and hoarse- 
ness ; a watery discharge from the eyes and nose ; eyes 
red and painful; transient stitches through the chest; 
often rheumatic pains in the back and extremeties. 
There are considerable remissions in the morning, and 
exacerbations in the evening During the first three 
or four days,.- the urine is high colored and free from 
sediment. About the fourth or fifth day, the febrile 
symptoms begin to decline; the urine then becomes 
pale and turbid, and the skin uniformly moist; the dis- 
charge from the nose and bronchia becomes thicker 
and yellowish. 

The existence of the latter cause is inferred from the circum- 
stance of this form of fever occasionally prevailing epidemi- 
cally, — extending itself over whole continents, and even passing 
from one continent to another. 

Causes. Atmospheric vicissitudes — a specific miasma, or 
a peculiar constitution of the atmosphere. 

Prognosis. Not in general a dangerous form of fever; 
most dangerous in infants and in very old people; apt 
to excite phthisis in those who are predisposed to it. 

Proximate Cause. Irritation and inflammation in the 
mucous membrane lining the respiratory passages, with 
disordered action of the cutaneous capillaries. 

Treatment. Moderate bleeding, in the young and robust; 
in the aged and in infants, generally unnecessary, and 
often improper. Mild laxatives useful in all cases. 
Mild diaphoretic drinks, such as infusion of eupatori- 
um, sage, camomile, &c. together with pulvis antimo- 
nialis, spiritus mindereri, or spir. nit. dulc. are impor* 



52 TYPHUS. 

tant remedies. Blisters to the breast, when the pneu- 
monic symptoms are severe. 
Mild Expectorants, to relieve the cough. 



Typhus is by no means so common a disease as is gene- 
rally supposed. The term typhous is frequently ap- 
plied to fevers essentially distinct from typhus. Syno- 
chous and catarrhal fevers are often improperly deno- 
minated typhous. 

Typhous divided into four periods, viz, the forming 
stage, the stage of invasion, the stage of excitement, 
and the stage of collapse. 

Symptoms — Of the forming stage. Lassitude, giddi- 
ness, and dull pain in the head; a peculiar uneasy sen- 
sation in the stomach, nausea, and sometimes vomiting; 
want of appetite; thirst, pale and shrunken counte- 
nance; tremor of the hands; eyes dull and heavy; 
muscular debility. This stage lasts from three to se- 
- ven days. 

Stage of Invasion. Slight chills, alternated with flushes 
of heat; tongue whitish or clammy; entire disgust of 
food; nausea and vomiting; a sense of weight and anx- 
iety in the prgecordium. This stage lasts from six to 
twenty-four hours. 

Stage of Excitement. Face full and flushed; pulse full, 
somewhat resisting, and accelerated; skin dry and 
warm ; lips parched ; thirst urgent, bowels constipated ; 
eyes red and watery; slight and transient delirium; vi- 
gilance; obtuseness of hearing; weight and oppression 
in the chest; tenderness and fulness of the hypochon- 
dria; catarrhal and peripneumonic symptoms; mind, 
about the third day, confused, as if stunned ; great re- 
luctance to mental and corporeal action. About the 
fourth day, a red military eruption often makes its 
appearance. Hildebrand regards this as an essential 
exantheme of this disease. The voice is at first rather 



TYPHUS. 53 

plaintive, but in the advanced periods of bad cases, it 
becomes guttural, and •' at last, truly sepulchral." The 
body exhales a peculiar odour, in this disease. This 
stage lasts usually about seven days ; at the end of this 
period, it terminates in the 

Stage of Collapse. This stage is characterized by: 
great prostration of muscular power ; torpor of the sen- 
sorial functions ; a very frequent and feeble pulse ; 
tongue brown, dry, at last black ; incrustation of the 
teeth with a blackish matter; short and feeble respira- 
tion; difficult deglutition; almost constant delirium; 
coma; tongue tremulous, and put out with difficulty; 
subsultus tendinum ; hiccough ; heat of the skin intense 
and acrid; unequal distribution of the animal tempera- 
ture; diarrhoea, with pain in the bowels, in the latter 
periods of severe cases; urine pale; tympanitic bowels; 
sometimes petechise. 

The foregoing sketch applies to typhus in its regular and 
simple form. In this form, there are manifest morning 
remissions, and evening exacerbations. Typhus is 
subject to various important modifications. In some 
instances, local inflammations supervene, forming 
what Dr. Armstrong calls 

Inflammatory Typhus. The organs most liable to be- 
come the seat of inflammation are, the lungs, the brain, 
the intestinal canal, the liver, and the peritoneum. — 
The mucous membrane of the alimentary canal and 
the arachnoid of the brain, the most commonly affect- 
ed. The theories of Broussais and Clutterbuck refer- 
red to. In some instances, the stage of excitement 
does not become developed, the stage of oppression 
continuing throughout the whole course of the disease* 
This variety constitutes Dr. Armstrong's. 

Congestive form of typhus. This modification is cha- 
racterized by : a want of reaction ; great prostration and 
sinking, from the commencement; deep pain in the 
head, and in vertigo ; face pale and dingy ; respiration 
anxious and oppressed ; pulse small and variable ; skin 



54 TYPHUS. 

cool, damp, and relaxed; countenance bewildered or 
vacant; eyes dull, watery, and red, or glairy and sta- 
ring, without redness ; bowels at first constipated — to- 
wards the conclusion, copious involuntary stools ; tongue 
pale and tremulous, becoming at last brown and rough ; 
petechia?; passive haemorrhages; coma; sometimes, 
from the beginning, complete torpor and insensibility. 
Dr. Armstrong's opinion that the depressed and prostrated 
state of the system depends on internal venous con- 
gestion, refuted. 

The internal congestions are most probably the consequence, 
and not the cause, of the impaired or depressed condition of 
the vital energies. When the remote cause of typhus acts 
with great intensity upon the system, the vital powers are sud- 
denly prostrated ; in consequence of which, the heart and the 
capillary system act feebly — ihe blood recoils from the surface 
to the central vessels, and gives rise to internal congestions, 
which the enfeebled heart is now unable to overcome. Pract. 
of Med. p. 151. 

Causes of Typhus. Typhus almost peculiar to the 
cold seasons of the temperate climates. Smith, Ferriar, 
and Wedekind, have seen it during the hotest weather 
in summer. Propagated by a specific contagion: evi- 
dence adduced in support of this assertion. Typhus 
occasionally originated by other causes than contagion 
— deficient and unwholesome food, and the contami- 
nated air of confined and crowded apartments, the 
most common causes of this kind. 

Upon the subject of the origin and mode of propagation of 
this disease, physicians are by no means unanimous. Some 
regard tvphus as always and essentially a contagious disease, 
while others deny that it is ever communicated in this manner. 
The weight of good testimony is in favor of the occasional ge- 
neration of the disease, by causes entirely distinct from conta- 
gion. When once generated, it may, and frequently does, 
spread from the sick to the healthy, in the manner of a contagion. 

Prognosis. Free and spontaneous vomiting, in the be- 
ginning, particularly when it relieves the giddiness, ge- 
nerally indicates a mild course of the disease. Hie- 



TYPHUS. 55 

morrhage from the nose, about the seventh day, is 
favorable. Very manifest remissions in the morning, 
are always a good sign. Moderate diarrhoea, during 
the first days, is favorable ; but when it occurs in the 
latter periods of the disease, it is a very bad sign. Great 
thirst, in the stage of collapse, is favorable ; so also is a 
moist tongue, in this stage. The absence of important 
or violent local inflammations, always a good sign. 
Diminution of the frequency of the pulse, and of the 
acrid heat of the skin, is favorable. Among the symp- 
toms which are particularly unfavorable, are: great 
change of the expression of the countenance, in the 
beginning of the disease; entire absence of thirst; con- 
stant and violent delirium; early petechia?; strong pe- 
ripneumonic symptoms ; swelling of the parotids. The 
most dangerous signs, in the last stage, are : blindness, 
involuntary flow of tears ; difficult deglutition ; palsy of 
the tongue; constant low murmuring ? and entire 
abandonment of himself; a very frequent and small 
pulse; pain in the region of the bladder; tenderness and 
tumefaction of the abdomen; floccitatio; continued 
motion of the hands and fingers; diarrhoea; insensibi- 
lity to the vesicating effects of cantharides; hiccough; 
aphthae in the mouth ; suppression of urine, &c. Pract. 
of Med. p. 159. 
Treatment. The first object is to remove as much as 
possible the remote cause, or to lessen its activity. 
With this view, the patient is to be removed from the 
confined and contaminated air in which the disease 
was contracted ; or if this cannot be done, the apart- 
ment in which he lies must be freely ventilated. 
Diversity of opinion, in relation to the treatment of ty- 
phus. Many physicians maintain, that no remedial 
treatment is adequate to interrupt the course of the dis- 
ease, when once completely formed. (Smith, Hilde- 
brand.) This I believe to be an erroneous opinion. 
Attention to the several stages of the disease, all-impor- 
tant in its remediate treatment. 



56 TYPHUS. 

In the forming stage, the indications are: to overcome 
the torpor of the external capillaries; to determine the 
circulation to the surface; and interrupt the morbid 
sympathetic actions throughout the system. For this 
purpose, emetics are highly serviceable; given soon af- 
ter the attack of the disease, they will often interrupt 
its course. After the operation of the emetic, 
Mild purgatives should be employed. Two or three 
alvine evacuations should beprocured daily. 

Diaphoretic ptisans, beneficial in this and the subse- 
quent stage; such as infusions of eupatorium, catnip, 
sage, &c. 

Calomel: In the early periods of the disease, this article 
is often decidedly useful. Slight mercurial influence, 
the most effectual means of arresting typhus in its early 
stage ; two grains of calomel may be given every four 
hours, until the gums become slightly inflamed. The 
constitutional influence of mercury generally perni- 
cious after the disease is fully developed — its benefits 
being restricted to the first five or six days. Calomel 
no less beneficial, in the early stages of congestive fe- 
vers. (Armstrong.) It has a powerful tendency to 
equalize the circulation; it raises the pulse, restores 
warmth to the skin, and increases the general energy, 
in such cases. 

In the stage of excitement, a more or less antiphlogistic 
treatment becomes necessary. Mild cathartics par- 
ticularly useful in this stage — they moderate at once 
the general excitement, the heat of the skin, and the 
force of the pulse. 

Cold Affusions. When the skin is hot and dry, in this 
stage of typhus, the affusion of cold icater is often 
highly beneficial. As the stage of collapse approaches, 
the temperature of the water should be raised. Cold 
affusions are improper, when the skin is below the 
natural temperature, and a sense of chilliness is pre- 
sent, or when there is profuse perspiration. Common 
salt may be advantageously added to the water, parti- 



TYPHUS. 57 

cularly when there is much prostration, When the 
heat of the body is unequally distributed, neither cold 
nor tepid affusions are proper: local inflammations 
also form an objection to cold affusions. In such cases, 
sponging the body with tepid water will sometimes do 
good. 
Diaphoretics, of the refrigerant class, useful during the 

stage of excitement. 
Bleeding, very rarely called for, in cases of simple typhus. 
Stage of Collapse. In this stage, stimulants and tonics 
are the appropriate remedies. Wine, serpentaria, ca- 
lamus aromatics, ammonia, opium, aether, phosphorus, 
camphor, and musk, are the most useful. Of these, 
wine, ammonia, camphor, and opium, are the best. 
When stimulants render the pulse fuller and slower, 
and the skin moist and cooler, they may be continued 
with confidence; but when the pulse becomes more 
frequent and corded, the countenance flushed, with an 
increase of restlessness and delirium, under their use, 
they are doing injury, and must be discontinued. Cam- 
phor particularly serviceable, where there is much de- 
lirium ; combined with nitre and calomel, useful even 
in an earlier period, when the disease is complicated 
with peripneumonic symptoms. Small doses of opium, 
with infusion of serpentaria, beneficial in pneumonic 
typhoides. Musk said to be particularly useful, in ty- 
phus of habitual drunkards. Opium serviceable, when 
in the last stage, where there is much restlessness, de- 
lirium, and other symptoms of nervous irritation ; com- 
bined with calomel and chalk, excellent to check the 
diarrhoea, which sometimes supervenes in this stage. 
Distinction between true and false debility. In the for- 
mer, there is an actual impairment of the vital powers ; 
in the latter, the powers of the system are oppressed, 
generally, in consequence of intestinal irritation. False 
debility sometimes occurs before the supervention of 
the stage of collapse— if, through mistake of its nature, 
stimulants are given, injury will be done. The diagno- 
sis between true and false debility. In false debility, 



58 TYPHUS. 

or prostration from intestinal irritation, there are, gene- 
rally, much jactitation ; flushed countenance ; eyes suf- 
fused ; extremities cold ; pulse irregular and very small ; 
hurried and anxious respiration; stupor; little or no 
delirium: it generally comes on suddenly. In debility, 
or sinking from an impaired state of the vital powers, 
the prostration usually comes on gradually; delirium is 
almost constant; skin hot, the heat being of the acrid 
kind, {color mordax;) the countenance is sunken and 
inanimate, with subsultus tendinum, &,c. Observations 
on the use of laxatives, in the stage of collapse. They 
are often highly serviceable. They should be given 
in conjunction with stimulants, such as ammonia, wine, 
alchohol, &c. One or two stools should be procured 
daily. 

Cinchona not in general of much use; when in the latter 
stage, the tongue and skin are dry, and there is much 
delirium, coma, and subsultus tendinum, the bark is 
improper. 

Blisters seldom serviceable, in simple typhus. 

Diet. Solid food injurious : farinaceous and mucilaginous 
substances, the only nutriments admissible. Barley 
water, and thin oat-meal gruel, should be freely allow- 
ed, in the stage of collapse. 

In typhus complicated with local inflammation, bleeding, 
in the second stage, is often indispensable: it must be 
early employed; delayed beyond the thirty-sixth hour 
after the beginning of the inflammation, it will most 
commonly do harm. Sufficient blood should be drawn 
at once, to make a decided impression on the system. 
Small bleedings , however frequently repeated, afford 
no permanent advantage. Cupping or leeching may 
be beneficially employed, when general bleeding is 
contra-indicated, 

Calomel with Opium, a valuable remedy after proper 
depletion, in typhus with pneumonic systems. One 
grain of each may be given every four hours. This 



TYPHUS. 



59 



remedy is hurtful, when the inflammation is seated in 
the brain. 

In prescribing depletory measures in typhus, even when con- 
nected with inflammation, it should be kept in mind, that there 
is always lurking at the bottom a radical' tendency to a state 
of exhaustion or prostration. 

Typhus in which reaction does not take place, or Con- 
gestive Typhus. Bleeding recommended by Arm- 
strong and others. Objections stated against this prac- 
tice, and reasons given in favor of the employment of 
stimulating frictions, warm applications to the exter- 
nal surface, and warm and gently stimulating drinks. 

Applications of this kind not only cause a determination to the 
surface, and thereby relieve the heart and arteries, but they 
also tend to invigorate and support the general energies of 
the system, by the stimulus they impart to the nervous extre- 
mities of the surface. 

Blisters, purgatives, calomel, and opium, are important 
remedies in this modification of the disease. Further 
observations on the beneficial influence of calomel, in 
congestive states of fever. While' this remedy is gi- 
Ten, with a view both to its purgative and constitution- 
al effects, warm and stimulating applications should be 
made externally. A blister to the epigastrium will of- 
ten do much service in such cases. (Armstrong.) 



60 INFLAMMATION IN GENERAL, 



CHAPTER IX. 



NFLAMMATION IN GENERAL. 



Phenomena. Pain, increased heat, redness, and swell- 
ing. Pract. Med. p. 172. 

1. Pain. Not always, though generally, present; gener- 
ally, the looser the instructive, the less pain; sometimes 
absent, in peripneumonia, gastritis, pericaradalis, &,c. ; 
inflammatory pain always increased on pressure, and 
may be thus distinguished from spasmodic pain. The 
nature of the structure inflamed modifies the character 
of the pain. The violence of the general febrile reac- 
tion, proportionate to the intensity of the pain. 

2. Increased heat. Not always present; actual degree of 
heat, never raised above 98°. The sensation of heat 
depends on the altered state of the sensibility of the in- 
flamed part. 

3. Redness. Almost an invariable phenomenon of in- 
flammation; arises from the intromission of blood into 
the serous capillaries ; generally remains after death ; 
redness, by itself, no certain sign of previous inflamma- 
tion ; the serous capillaries may become injected with 
red blood in articido mortis, although sound before; 
importance of this knowledge, in autopsic examina- 
tions. 

4. Swelling. The effort of effusion into the surrounding 
cellular tissue; the firmer the structure, the less swell- 
ing. 

Inflammation is located in the capillary system. The 
more abundant the capillaries of a part, the more apt 
is it to become inflamed. The mucous, serous, cellu- 
lar, and dermoid systems, being very vascular, are very 



INFLAMMATION IN GENERAL. 61 

subject to inflammation ; the contrary obtains with the 
osseous, the cartilaginous, and the tendinous structures. 
(Bichat.) 

JEtiology. Inflammation may be produced — 1. By the 
direct operation of irritants on a part. % By the indi- 
rect operation of irritants on parts, through the medi- 
um of the nervous system. 3. By general irritated vas- 
cular excitement. 4. By metastasis. 

Whatever be the exciting cause of inflammation, the follow- 
ing changes take place in progress of its evolution: viz, 
irritation; then alteration of the vital properties; and 
finally, an afflux of Mood to the part. These changes 
often succeed each other so rapidly, that they seem to 
aris^ simultaneously . A change of the vital proper- 
ties is essential to inflammation; preternatural deter- 
mination to a part, without altered sensibility and con- 
tractility, constitutes congestion, or local plethora-— 
not inflammation. (Bichat.) 

Are the capillaries of an inflamed part in a state of debil- 
ity, arid is the velocity of the blood circulating in them 
diminished — or, are they in a state of increased action? 
Vacca, Lubbock, Allan Phillip, and Hastings, have 
written in support of the former opinion; but the sub- 
ject is still subjudice. 

My own view on this subject is, that the inflamed capillaries 
ought to be regarded as being in a state of irritated excite- 
ment; and that this irritated condition may be connected either 
with anincreased or with decreased power of action. In this 
respect, local inflammation corresponds with that, general irri- 
tated vascular excitement, which constitutes fever. The heart 
and arteries are in a state of irritated action, with increased 
power of acting in synocha. In typhus, there is also general 
irritated excitement; but it is connected with a fundamental 
debility of the vital powers. There is therefore, according 
to my apprehension, a typhous and a synochal state of inflam- 
mation ; and this corresponds with the results we obtain from 
remedial applications. May we not explain these different 
diatheses of inflammation, by the greater or less degree of or- 
ganic injury sustained by the nervous filaments of the inflamed 
capillaries? When a part is irritated, so as merely to exalt 
the sensibility of the capillaries, by exciting their nervous tex- 



62 INFLAMMATION IN GENERAL. 

ture, the consequent inflammation will probably be one of in- 
creased capillary action, and demand sedatives for its cure: 
When, on the contrary, the irritating cause acts with such vio- 
lence as to cause structural lesion in the nervous extremities, 
the inflammation resulting from its action will, I conceive, be 
characterized by debility, and stimulating applications, as is 
the case in scalds and burns. 

Termination of inflammation. These are quadruple: — 
Pract. of Med. p. 175. 

1. Resolution. Inflammation is said to terminate in re- 
solution, when it declines and disappears without any 
structural lesion, or perceptible discharge. Resolution 
is more prompt, in proportion as the organ affected 
possesses ahigherdegree of vitality ; in the serous mem- 
branes, the progress of inflammation is particularly 
rapid. (Bichat.) Resolution is often accompanied by 
an increase of the natural secretions of the part: this is 
particularly noticed in the mucous and serous mem- 
branes ; also, in rheumatic inflammation. 

2. Effusion. The effusion may be blood, lymph, or se- 
rum. The termination by effusion of blood, most 
common in the mucous membranes; effusions of 
lymphand serum, almost peculiar to the serous mem- 
branes — the former fluid forms a bond of union be- 
tween the serous membranes. Such adhesions never 
occur in the mucous membranes. Serum seldom 
abundantly exhaled, until the inflammation hasassum- 
ed a chronic or sub-acute character. Dropsies are the 
consequence of this mode of termination. Effusion of 
lymph into the substance of the solid viscera, result in 
induration. 

3. Suppuration. The cellular, serous, and mucous tis- 
sues, are most prone to this termination; the bones 
and tendons never suppurate. The mode of suppura- 
tion different in the different structures ; in the mucous 
membranes, it is a morbid secretion, the pus having a 
whitish, cream-like appearance . In the serous mem- 
branes, pus is formed by a kind of exhalation, and is a 
thin whitish, or whey-like fluid, sometimes mixed with 



INFLAMMATION IN GENERAL. C£$ 

flakes, In the cellular tissue, pus collects in circum- 
scribed cavities, called abscesses, and is of thick and 
uniform consistence and pale yellow colour, exhibiting 
to the microscope minute globules suspended in a se- 
rous fluid. Symptoms denoting the occurrence of sup- 
puration, in the inflammation of eternal organs: a sen- 
sation of weight in the inflamed part; change from the 
acute to a dull throbbing pain ; rigors ; pulse losing its 
tension and hardness, and becoming soft and full ; night 
sweats, and other symptoms of hectic. 
4. Gangrene. Never occurs in the cartilages, nerves, or 
bones. The cellular, mucous, and serous tissues, are 
most prone to it ; more common in the peritoneum, 
than in any of the other serous membranes; of the mu- 
cous membranes, than lining the alimentary canal is 
most subject to it. The occurrence of gangrene is 
denoted by, sudden cessation of pain ; sinking pulse ; 
cold extremities ; cold sweat; delirium; and cadaverous 
countenance. 

There exists in the different forms of inflammation, an "origin- 
al disposition to terminate in one mode, rather than another : 
thus, in boil and whitlow, it is to suppurate; in carbuncle, to 
slough ; and in mumps, to resolve : and this disposition is so 
strong, that it is very difficult to procure any other termina- 
tion." 

Varieties of inflammation. Inflammation occurs under 
five prominent modifications, corresponding to the five 
elementary tissues — viz. the cellular membrane and 
parencJiy ma of the solid viscera; the serous mem- 
branes ; the mucous membranes ; the skin, or dermoid 
tissue; and the fibrous membranes. 

d. Inflammation of the cellular membrane, or 
'phlegmonous inflammation. Characterized by, 
great swelling, throbbing pain, and by its mode of 
suppurating; the pus being collected in circum- 
scribed cavities. Diffuse cellular inflammation, 
% Inflammation of the serous membranes, or 
serous inflammation. Pain very acute and Ian- 



64 INFLAMMATION IN GENERAL. 

cinating — rapid in its course; no tumefaction; 
much sympathetic excitement of the general san- 
guiferous system, terminating in the exudation of 
coagulable lymph or serum, or the secretion of a 
whey-like pus; adhesions are peculiar to this va- 
riety of inflammation ; it rarely terminates in gan- 
grene. 

3. Inflammation of the mucous membrane, or mu- 
cous inflammation. Almost always produced 
by sudden atmospheric vicissitudes, in conse- 
quence of the close sympathy which subsists be- 
tween these membranes and the skin. Sometimes 
prevails epidemically. Pain not very severe ; un- 
attended with swelling of the subjacent cellular 
tissue ; concomitant fever not intense ; never termi- 
nates without an increase of mucous secretion. 
No adhesions ever formed. 

4 . Inflammation of the skin, or erysipelatous in- 
flammation. Pain of the stinging or burning 
kind ; spreading ; forming vesicles ; never suppu- 
rating in circumscribed cavities ; dependent on a 
specific cause. 

5. Inflammation of the fibrous membranes, or 
rheumatic inflammation. Pain intense and ach- 
ing ; does not terminate in abscess or suppuration ; 
terminates by an exudation of a gelatinous matter ; 
or by earthy depositions; is wandering, accom- 
panying fever always synochal; rarely proves 
fatal, except by metastasis to organs essential to life # 

Diagnosis of internal inflammations. The existence 
of internal inflammation is ascertained by : the continu- 
ance of the pain ; the appearances of the blood ; the 
state of the general vascular excitement; the effects of 
external pressure; the effects of position; the character 
of the functional derangements ; the temperature of the 
skin ; and the nature of the exciting causes. 



PHRENITIS. 65 



CHRONIC INFLAMMATION. 



Chronic Inflammation is generally, though not always, 
the consequence of acute inflammation. Doctrines 
concerning its nature. 

The effects of Chronic Inflammation, — dropsical effu- 
sions, and tuberculated accretions in the serous mem- 
brane ; phthisis, diarrhoea, dyspepsia, and various other 
affections in the mucous membrane, &,c. 

Treatment. The indications in the treatment of acute 
inflammation, are — 1. To diminish the momentum of 
the general circulation ; 2. To drive the blood from the 
inflamed part; 3. To alter the action of the inflamed ca- 
pillaries; and 4. To change the inflammatory condi- 
tion of the blood. 



CHAPTER X. 



INFLAMMATION OF THE BRAIN. 



Encephalic Inflammation is divided into two varieties — 
viz. Phrenitis and Arachnitis. 

PHRENITIS. 

In Phrenitis, the substance of the brain, as well as its 
membranes, are involved in inflammation. 

Symptoms. Synocha; fixed and intense throbbing pain 
in the head ; face full and flushed ; eyes inflamed ; into- 
lerance of light; heariug at first morbidly acute, at last 



66 ARACHNITIS. 

almost complete deafness ; furious delirium from the 
commencement, and constant wakefulness. 

Causes. Insolation. Distinguished from mere syno- 
cha, with high cerebral excitement, by the following 
circumstances. In phrenitis, there is always promi- 
nent derangement of the organs of sense — in synocha, 
hearing and vision are but little affected. In phreni- 
tis, the internal functions are always much disturbed — 
in synocha, this is rarely the case. In synocha, the 
pulse is hard, full, frequent, and vibrating, from the 
beginning — in phrenitis, it does not becmoe so until 
the inflammation is fully formed. 

Prognosis. Haemorrhage from the nose is favorable, — 
from the bowels, in the advanced stage, unfavorable; 
coma supervening to delirium, a fatal sign. 

Autopsic Phenomena. Flakes of coagulable lymph, pus, 
and serum between the membranes ; sometimes 'adhe- 
sions; abscesses in the substance of the brain; ero- 
sions of the dura mater. 

Treatment. Vigorously antiphlogistic. Prompt and de- 
cisive bleeding, both general and local ; cold applica- 
tions to the shaven scalp; cathartics; the refrigerant 
diaphoretics ; blisters to the nape of the neck, after the 
febrile excitement has been moderated by depletion. 
The head should be kept in an elevated position, and 
the chamber dark, noiseless, and cool. Digitalis and 
nitre, after the disease has been in some degree subdued. 
Pract. of Med. p. 257. 

ARACHNITIS, OR HYDROCEPHALUS ACUTUS. 

This is a much more common form of encephalic inflam- 
mation than the preceding one. It has of late years 
been extensively investigated, by Martinet and Ducha- 
telet, of Paris, whose pathological researches, in rela- 
tion to it, are highly interesting and valuable. I treat 
of hydrocephalus and arachnitis under the same head ; 
for it is now placed beyond all doubt, that the malady 



ARACHNITIS. 67 

known and described under the name of hydrocepha- 
lus, is neither more nor less than arachnoid inflamma- 
tion. The term hydrocephalus is indeed altogether 
inappropriate to the disease; for instead of directing 
the mind to the primary and essential affection, it has 
reference only to one of the occasional consequences of 
the disease. Pract. of Med. p. 262. 

Symptoms. Often very gradual in its approach. In this 
case, there are transient pains in the head and abdo- 
men ; the patient is dull, fretful, restless, and discon- 
tented ; countenance pale, with an occasional flush on 
-the cheek; the brows contracted, appetite variable; 
bowels torpid, or mucous diarrhoea ; starting and grind- 
ing the teeth during sleep. After these symptoms have 
continued for an indefinite time, hose which characte- 
rize the disease in its full development come on : these 
are — severe pain in the head, nausea and vomiting; 
deep sighing, occasional somnolency, and slight deli- 
rium; very dilated or contracted pupils; an expression 
of surprise and stupor in the countenance; slight red^ 
ness of the conjunctiva; paralysis of the upper eye- 
lids; squinting; eyes turned up, so as to hide the cornea 
under the upper lid ; towards the last, constant somno- 
lency, interrupted by spells of great anxiety and rest- 
lessness, or fits of violent and frightful screaming, para- 
lysis of one side; convulsions; death. The patient can 
seldom be induced to utter more than monosyllables. 
The pulse is at first irritated, frequent, and tense; when 
somnolency comes on, it becomes slower; towards the 
termination, it again becomes very frequent. 

The disease is sometimes ushered in by convulsions. I 
have seen it come on without any febrile excitement, 
the countenance remaining pale, with cold hands, deep 
sighing, a peculiar expression of surprise, vomiting, and 
constipation. It sometimes comes on in the shape of 
a remitting fever. After a few day's languor and 
drooping, fever ensues, attended with head-ache, flush- 
ed countenance, tenderness of the abdomen, stupor du- 



68 ARACHNITIS. 

ring the exacerbations, the patient screaming and start- 
ing up in great alarm, great irritability of the stomach, 
obstinate constipation, &,c. 

Predisposition. Hereditary, in some instances; the 
scrofulous diathesis predisposes to it. 

Exciting causes. External injuries; dentition; intesti- 
nal irritation; suppression of serous discharges of 
cutaneous eruptions, particularly about the head ; fre- 
quently the consequence of cholera, whooping cough, 
measles, and scarlatina. 

Diagnosis. Arachnitis to be distinguished from infan- 
tile remittent, by the regularity of the remissions in the 
latter, and the character of the stools. In infantile re- 
mittents, the stools are fetid, and of a dark-brown or 
mud-like appearance — in arachnitis, they are dark- 
green and glairy. 

The connexion between arachnitis and cholera infan- 
tum pointed out. 

Prognosis. Always highly dangerous ; deep somnolen- 
cy, paralysis, blindness, strabismus, and convulsions, 
indicate a fatal termination. 

Autopsic phenomena. Commonly, general redness of 
the arachnoid membrane; sometimes it is opaque and 
thickened, with a purulent, sero-purulent, or sero-gela- 
tinous effusion on the surface, more or less serous effu- 
sion into the ventricles, and between the lamina of the 
arachnoid. 

Treat3ient. The indications are — 1. To moderate the 
general febrile excitement; 2. To subdue the local en- 
cephalic inflammatory affection of the brain ; and 3. 
To remove those causes which tend to keep up a pre- 
ternatural determination to the brain. 

For this purpose are employed : 

Bleeding, copious and prompt, both general and local. 
The blood should be suffered to flow, until an approach 
to syncope is induced ; — leeching on the crown of the 
head. (Duchatelet.) Generul always to be premised 
to local bleeding. 



ARACHNITIS. 69 

Purgatives are of great importance. Calomel the best 
purgative, on account of the torpor of the liver in the 
early period of the disease. Where worms are sus- 
pected, spigelia and senna should be used. 

In cases depending on intestinal irritation, — and the majori- 
ty of cases in infancy are of this kind, — violent purging is 
improper. Mild laxatives, however, are of the utmost impor- 
tance. Where the disease has been brought on by external in- 
juries to the head, or where the arachnoid inflammation is 
idiopathic, the more active purgatives may be employed with 
advantage. 

Revulsive applications. Cold applications to the head ; 
blisters ; pediluvium ; cupping. Blisters are usually ap- 
plied to the shaven scalp — I prefer placing them be- 
hind the ears, or on the nape of the neck, while ice or 
or other cold applications are made to the scalp, and 
sinapisms laid on the soles of the feet. 

Mercury: with a view to its constitutional influence, one 
of our most useful remedies in this disease. Percival, 
Dobson, Rush, Cheyne, and others, mention cases 
which yielded to it. 

James's Powder. Dr. Stocker states, that this article 
has a decided tendency to diminish the circulation to 
the head ; and of the truth of this observation, I have 
had repeated evidence. It is best given in combination 
with calomel, in this disease. 

Dover's Powder. Drs. Brooke, Percival, Cheyne, and 
Crampton, speak highly of the efficacy of this article 
in hydrocephalus. In cases depending on intestinal 
irritation, after adequate depletion, it may sometimes 
prove serviceable. In the idiophatic form of the dis- 
ease, however, all opiates are injurious. 

Digitalis has been recommended; and, from its tendency 
to lessen the action of the heart and arteries, it may un- 
doubtedly be employed with occasional advantage. 



"70 ERETHISM OF THE BRAIN. 

ERETHISM OF THE BRAIN. (Dr. Nicholl.*) 

Infants are subject to a morbid condition of the cerebral 
structures, which appears to consist in a highly irrita- 
ble or sensitive state of the nervous centre ; being unat- 
tended by inflammation, or increased momentum of 
blood in the cerebral vessels. I have frequently wit- 
nessed this affection, and think it a subject of sufficient 
importance and interest, to introduce it to the attention 
of the medical student. It is characterized by: wake- 
fulness; irritable temper; retina very sensible to light; 
contracted pupils, much action of the limbs ; head often 
moved from side to side, extreme fretfulness ; frequent 
crying, without any apparent cause — the little patient 
being " soothed only by tossing it, by carrying it about, 
putting it to the breast, or letting it suck the cheek of 
the nurse, or its own fingers ;" increased secretion of 
tears; bowels generally relaxed, without a disordered 
state of the stools. When sleeping, the child often 
starts, and is readily awakened ; when awake, it starts 
at the slightest noise, or on being slightly touched ; of- 
ten shrieks out, as if it were pricked with a pin ; the 
fists are frequently clenched, the thumb being bent in, 
and the fore-arms bent upwards on the arms. Some- 
times the child presents, for a short time, a state of 
opisthotonos, " its legs being drawn up, and the head 
thrown backwards." 

In adults, this erethismal state of the brain shows itself by "ir- 
ritability of temper," inability to bear the effects of the most 
trifling sounds, wakefulness, restlessness, febrile symptoms," &c. 

Subjects of a scrofulous diathesis are particularly predis- 
posed to this morbid cerebral irritability. 



* Practical Remarks on Disordered States of the Cerebral Struc- 
tures, occurring in infants. By Whillock Nicholl, M. D. &c. &c. Lon- 
don, 1821. 



SOFTENING OF THE BRAIN. 71 

Causes: dentition ; gastric irritation, from various causes; 
torpor of the liver, &c. 

Treatment. Exercise in the open air; small doses of 
ipecac, compos. ; a mild unirritating diet ; leeches to the 
temples; lancing the gums; mild aperients and diure- 
tics; pediluvium. 



SOFTENING OF THE BRAIN. 

This form of cerebral disease has of late been abundant- 
ly noticed by the French pathologists. Recamier, 
Bayle, Cayol, Brichereau, Rostan, and Lallemand, 
have published numerous interesting observations, con- 
cerning its symptoms and pathology. The disease con- 
sists in a softening, or kind of liquefaction, of a portion 
of the brain, with vascular injection of the rest of its 
substance. Rostan divides the disease into two peri- 
ods. 

The symptoms of the Jirst period are: a fixed and vi- 
olent pain in the head, often continuing for several 
months ; vertigo ; obtuseness of the mental faculties, 
the memory being weak, and the ideas confused; 
questions are answered after long hesitation ; dejection; 
querulousness ; indifference to surrounding occurrences; 
drowsiness; tingling and numbness in the fingers; fre- 
quently perverted vision, and occasionally total blind- 
ness; dull hearing, — sometimes very acute; frequently 
nausea and bilious vomiting; tenderness of the epigas- 
trium ; constipation ; pulse variable, sometimes hard and 
full; occasionally there is delirium, with fever, and 
much agitation. 

The second period is characterized by a gradual or sud- 
den paralysis of one limb, sometimes of half the body; 
consciousness and intellect remain ; questions are an- 
swered with very great difficulty, the patient generally 
expressing his desires by automatic movements ; some- 



72 ACUTE GASTRITIS. 

times perfect coma ; death commonly follows, in two or 
three days. 

The corpora striata^nd thalami opticorum, have been 
most frequently found the seats of this softening. 

The inflammatory nature of this disease has been much 
doubted by some ; but the facts and arguments addu- 
ced by Lallemand, render the opinion of its being of an 
inflammatory character exceedingly probable. This 
writer thinks that the softening is tk the effect of inflam- 
mation arrested in its course by death, before purulent 
suppuration has had time to take place." 

Diagnosis. A contraction of the flexor muscles of the 
limb, is particularly characteristic of this disease. — 
" Sometimes," says Lallemand, " this amounted only to 
simple rigidity of the limbs; at others, it was carried so 
far, that the patient's fist was kept rigidly applied to the 
shoulder, and the heel to the buttock." Contrary to 
what takes place in apoplexy, the mouth is drawn to- 
wards the paralyzed side. 

Treatment. General and local bleeding; sinapisms to 
the feet; cold applications to the head; cathartics; 
blisters to the back of the neck ; calomel, with a view 
to its salivant effect. 



CHAPTER XI. 



ACUTE GASTRITIS, 



Symptoms. Burning and lancinating pain in the sto- 
mach ; frequent vomiting, particularly on swallowing 
fluids; urgent desire for cold drink; constipation ; fever, 



ACUTE GASTRITIS. ?3 

with a small, hard, and frequent pulse. After a draught 
of cold water, a temporary mitigation of the gastric 
pain occurs; difficulty of swallowing; disgust of warm 
drinks ; great prostration of strength from the begin- 
ning. Pract. of Med. p. 106. 

Diagnosis. Distinguished from spasm and flatulent 
pains, by the following circumstances. In gastritis, 
the pulse is small and tense — in cramp, it is generally 
natural In the former, there is violent and frequent 
vomiting — in the latter, this rarely occurs. Warm 
drinks excite instantaneous vomiting, in gastritis — in 
spasm, they do not. The pain of gastritis is continu- 
ous — that of spasm is paroxysmal or intermitting. In 
gastritis, the patient lies on his back, without moving, 
with his knees drawn up— in cramp, he sits up, with 
his body bent forward, or writhes about during the vio- 
lence of the pain. In gastritis, the skin is hot and dry 
— in cramp, it is generally cool and moist. Hiccough 
is a common symptom in gastritis— -in spasm, it sel- 
dom occurs. 

Autopsic phenomena. The inner coat of the stomach 
thickened and red, with gangrenous, eroded, or ulcer- 
ated spots. 

Causes. Mechanical irritants ; poisons ; cold water, swal- 
lowed while the body is in a state of free perspiration; 
over-distention with food or drink; the sudden applica- 
tion of cold to the surface; suppression of habitual dis- 
charges, &c. 

Treatment. Bleeding; the smallness of the pulse and 
prostration in the beginning of the disease, no objec- 
tion, but on the contrary a strong indication of the ne- 
cessity of prompt and copious depletion. The pulse 
becoming fuller and less frequent, is an evidence that 
the disease is yielding. 

Blisters over the epigastrium, are next in importance to 
bleeding; they are to be preferred to leeching, and 
should be early applied. Costiveness must be obviated 
by enemata. Cathartics, and the usual internal anti- 
K 



74 CHRONIC GASTRITIS. 

phlogistics wholly inadmissible. Copious draughts of 
bland, mucilaginous drinks, beneficial. 
Opium, a valuable remedy in this disease: after the vio- 
lence of the local and general inflammatory excite- 
ment has been moderated by depletory measures, I 
know of no remedy that is so useful in allaying the vo- 
miting and gastric pain, and producing a general and 
salutary diaphoresis, as opium in large doses. I have 
given two grains of this narcotic, in some exceedingly 
violent cases, with the happiest effect. 

CHRONIC GASTRITIS. 

Chronic inflammation of the mucous membrane of the 
stomach, is of much more frequent occurrence than is 
generally supposed. The worst forms of dyspepsia, 
and all that host of inveterate gastric and bilious de- 
rangements, of which so much is heard, and the true 
nature of which is so often misunderstood, are, in nine 
cases out of ten, the consequence of a more or less 
phlogosed condition of the mucous membrane of the 
stomach. We are indebted to the French patholo- 
gists, and more especially to Broussais, for much new 
and valuable information, in relation to this variety of 
phlegmasial disease. Pract. of Med. p. 191. 

Symptoms. A pricking, lancinating, or burning pain in 
the epigastric or hypochondriac region; the pain is 
constant and harassing, generally confined to a very 
circumscribed spot, and often attended with a feeling 
of constriction; sometimes a sensation is felt, as if a 
ball were pressing on the diaphragm ; at others, as if 
a bar were fixed across the stomach, impeding degluti- 
tion; depraved and impaired appetite, often general 
abhorrence of food ; indigestion, vomiting, or nausea; 
load at the stomach after eating; pulse but little excited, 
and heat of the surface natural, except during diges- 
tion, when they are a little elevated ; great costiveness 
during the first period, but mucous diarrhoea after the 



CHRONIC GASTRITIS. 7& 

disease has become inveterate; the patient becomes 
irritable, dejected, taciturn, discontented ; tongue of the 
color of logwood, with a strip of thin fur along its cen- 
tre. In inveterate cases, emaciation, with the shin 
drawn tight over the muscles, so that it cannot be 
pinched up. This tightness of the skin is the most 
constant diagnostic sign of the disease. Mere gastric 
debility may be distinguished from it by the effects of 
an emetic : when fever, pain, and anorexia, become in- 
creased after the operation of an emetic, we may be 
sure of the existence of high irritation, or phlogosis, 
in the mucous membrane of the stomach. 

Mr. Barras has published some interesting observations, in 
the Revue Medicale, for November and December 1825, on 
gastralgia, and the frequency with which it is mistaken for 
gastritis. He gives the following, among others, as diag- 
nostic symptoms between those two affections. 

1. "In chronic gastro-enteritis, the pain is generally obtuse; 
often felt only on pressure ; is never absent. Gastralgic pain, 
on the other hand, is often extremely violent; is often, when 
most violent, relieved, rather than increased by pressure. 
It often radiates from the epigastrium towards the thoracic 
parietes, the back, and the shoulders ; is of an intermittent 
character, sometimes entirely disappearing, to return with 
more or less violence. 

2. In chronic gastritis, the tongue, which is generally red on 
the sides and at the top, is covered in the middle with a kind 
of dry mucous crust, resembling a false membrane, the 
breath is fetid, with a bitter taste in the mouth ; there is thirst. ' 
In gastralgia, the tongue is white; saliva abundant, no 
thirst, but sometimes a repugnance even to liquids. 

3. In gastritis, the appetite is always bad, and sometimes 
amounts to a universal disgust towards every kind of food. 
In gastralgia, the appetite is variable, null, slight, natural, 
often greater than in health. 

4. In chronic gastritis, the ingestion of a small quantity of food 
renews the patient's sufferings; excites a febrile movement in 
the system, and the digestion is always imperfect. There is 
often rejection of the food by vomiting, a little time after eat- 
ing; or if there be no vomiting, the patient is oppressed dur- 
ing the digestive process, with a sense of weight, distention, 



76 CHRONIC GASTRITIS. 

nausea, acid or acrid eructations, and irritation of the bow- 
els, or diarrhoea, in the advanced stages. In some cases of 
gastralgia, the pain is relieved, at least for a time, by eat- 
ing food in considerable quantity, and the digestion is com- 
plete, or even too quick. In the generality of cases, howev- 
er, of gastralgia, the presence of food in the stomach renews 
the pain; but not till some time after eating, generally one, 
two, or even three hours; at which time the patient expe- 
riences weight and mal aise at the epigastrium, as if there 
was a foreign body in the stomach. There are nausea, bor- 
borygmi, flatulent colic, eructations of air, but without fetor 
or causticity. Sometimes indeed, patients will taste the ali- 
ments that they have swallowed in the air which they 
eructate, but digestion is completed, and diarrhoea is very 
rare. Constipation is generally obstinate, and the urine, 
especially when the gastralgia is in a high degree, is usually 
pale, voided frequently, and in small quantities at a time. 

5. Chronic gastritis never fails to impair the process of nutri- 
tion, inducing hectic fever, characterized by hardness and 
frequency of the pulse, heat of the skin, and evening exacer- 
bations, with loss of flesh and strength, sallowness of the 
countenance, with a peculiar dark tinge, and finally death. 

6. In some violent and prolonged cases of gastralgia, the pa- 
tients experience difficulty of breathing, palpitations of the 
heart, wandering pains, and peculiar sensations of coldness, 
and especially in the arms, loins, and lower extremeties. 
The sleep is sometimes good, sometimes agitated, sometimes 
null; yet, in the mornings, the patient gets up refreshed, and 
feels quite well, till breakfast renews the gastric sensibility. 
Nothing of this kind obtains in latent gastritis. 

7. Those who are affected with chronic inflammation of the 
digestive tube, are melancholy, morose, and impatient; but 
this is nothing to the state of moral depression and anxiety 
which obtains in gastralgia, In this last, there is ineffable 
despondency ; disgust of life, or fear of death in the extreme ,- 
the slightest sensation in the stomach, awakens the patient's 
terrors; he is tremblingly alive to every look of his physi- 
cian — to every word which is spoken by his friends respect- 
ing his complaint; he is afraid of taking any thing into his 
stomach, as he knows, by doing so, he will aggravate the 
complaint; he is convinced that his disease is mortal — be- 
comes entirely absorbed by his own sensations, and indiffer- 
ent to every thing else. But any diminution or cessation of 
the gastralgia, immediately changes the scene from despair 
to sanguine hope — to be again reversed on the slightest ac- 
cession of the pain.'"' 



ACUTE ENTERITIS. 77 

Causes, Indigestible and irritating diet ; acrid medicines 
received into the stomach ; the abuse of spirituous li- 
quors; exposure to a cold and damp atmosphere; fre- 
quently the consequence of acute gastritis. 

Treatment. Almost the whole remediate management 
depends on the proper regulation of the diet, together 
with the employment of leeches or blisters to the epi- 
gastrium. The food must be chiefly liquid, and as 
mild as possible ; mucilaginous fluids, such as decoc- 
tions of barley, rice, or thin gruels, are the best articles 
of food; animal jellies are proper — so is boiled milk, 
with water. I have found small doses of ipecacuanha 
and calomel in combination, decidedly advantageous; 
— one-eighth of a grain of the former, with one fourth 
of a grain of the latter, may be administered three times 
daily. A weak emulsion of bals. capaiva has also 
been found serviceable: this article, though irritating, 
has a peculiarly beneficial operation in chronic phlo- 
gosis of the mucous membranes. 

ACUTE ENTERITIS. 

Symptoms. Fixed, burning pain in the abdomen, gene- 
rally about the umbilical region ; obstinate constipation, 
nausea and vomiting, the latter being sometimes so se- 
vere, as to communicate inverted action to the intes- 
tines, and produce stercoraceous discharges by the 
mouth; fever, with a small, frequent, and tense pulse; 
very rarely, the pulse is full and hard ; dry and red 
tongue, urgent thirst; dry and hot skin; urine high co- 
lored, and small in quantity ; respiration short, and per- 
formed by the intercostals exclusively ; position on the 
back, with the knees and shoulders elevated. 

When the upper part of the colon is affected, acute 
enteritis is often attended by symptoms of pleuritic or 
hepatic inflammations. 

Diagnosis. In pleurisy, the pulse is full and hard — in 
enteritis it is small and tense ; abdominal respiration in 



78 ACUTE ENTERITIS. 

pleurisy — not so in enteritis; abdomen tender, and 
painful to pressure, in enteritis — not so in pleurisy. 

Spasmodic pain distinguished from enteritis, by: the 
paroxysmal character of the pain ; the constant change 
of position ; the ease obtained by pressure on the abdo- 
men; natural temperature and moisture of the skin, and 
the want of thirst, which characterize spasm of the in- 
testines. The reverse, in all these circumstances, ob- 
tains in enteritis. 

The only favorable termination is in resolution ; sup- 
puration is rare ; gangrene is more common, and is al- 
ways fatal. The disease would seem sometimes to 
prove fatal, without any of the usual terminations of in- 
flammation. Pract. of Med. p. 199. 

Prognosis. Always very uncertain ; an almost imper- 
ceptible pulse, with cold hands and feet, indicate great 
danger; diffusion of the pain throughout the abdomen 
dangerous ; tumid and tympanitic abdomen, a bad sign; 
frequent vomiting, in the latter stage, highly unfavorable. 

Treatment. Copious depletion in the early stage. Dif- 
ference of opinion concerning the propriety of employ- 
ing active cathartics ; mild laxatives very useful ; dras- 
tic purgatives,howeyer, are improper; decisive bleed- 
ing an essential preliminary to the use of laxatives ; 
calomel, or castor oil, in conjunction with opium, good 
articles for the purpose. Opium an important remedy 
in the latter period of the disease, after the violence of 
the local and general inflammatory excitement has been 
moderated by depletory remedies. It promotes the 
operation of purgatives, determines to the surface, pro- 
duces diaphoresis, and relieves the distressing pain sufc 
fered in this disease. When opium is given, it should 
be in large doses. Two grains may be given every 
two hours. Pract. of Med. p. 201. 

Large doses of opium have a much less tendency to increase or 
support the inflammatory diathesis, than small ones. The sen- 
sibility and irritability of the system are greatly reduced, by a 
large dose of this valuable narcotic; and with them, all those 



DYSENTERY. 79 

morbid phenomena which depend on, or are influenced by, a 
preternaturally sensible state of the system, are moderated. 

Blisters to the abdomen are indispensable. Leech- 
ing, and fomentations are recommended ; blistering, 
however, is preferable. 

The ordinary internal antiphlogistic remedies fre- 
quently do harm. Mild diluents, of the mucilaginous 
kind, very useful ; great attention to the diet, necessary 
during convalescence; the most unirritating fo%d is 
alone admissible. 



In the variety of enteritic inflammations noticed above, the 
inflammation is seated chiefly, if not exclusively, in 
the peritoneal coat of the intestines. Obstinate costive- 
ness is an essential symptom of this form of the disease. 
There is another variety of acute enteritis, in which the 
mucous membrane of the intestinal tube is the exclu- 
sive seat of the inflammation; and which is essentially 
attended by mucous stools, more or less Mixed with 
blood, and by tenesmus. This latter form of the dis- 
ease constitutes: 

DYSENTERY. 

Character. In inflammation of the mucous membrane of 
the intestinal canal, attended by fever, frequent bloody 
or mucous stools, griping, and tenesmus. Pract. of 
Med. p. 206. 

Symptoms. The fever generally becomes developed, 
before the enteritic symptoms — sometimes the reverse 
takes place. The violence of the tenesmus, a pretty 
correct criterion of the violence of the disease ; tormina 
most severe, just before the calls to stool ; constant 
soreness of the abdomen ; evacuations sometimes whol- 
ly mucous ; more commonly mixed with blood — occa- 
sionally, altogether blood ; smell of the stools, at first, dis- 
agreeable, but not fetid — towards the last, of a cadav- 
erous, penetrating fetor. In violent cases, colliquative 



80 



DYSENTERY. 



diarrhoea sometimes come on, a few days before death. 
Tongue at first white, afterwards brown, rough, and 
dry along the middle, with a red and moist border; 
clean and florid along the edges and tip, or smooth, 
clean, and deep red over its whole surface, in protract- 
ed cases. In some very protracted cases, the tongue 
and fauces become aphthous. ' The stools are never 
colored with bile. The skin is always dry. 

Autopsic appeara?ices. The traces of inflammation are 
sometimes confined entirely to the colon; more com- 
monly, however, marks of inflammation appear through- 
out the whole intestinal canal; but even where this is 
the case, the colon and rectum exhibit much stronger 
marks of disease than the other portions of the intes- 
tines. Very frequently, the mucous membrane of the 
colon and rectum is found ulcerated, thickened, soft, 
pulpy. The liver is frequently found to have suffered 
structural derangement; it is most commonly enlarged, 
and in a state of great sanguineous congestion. Pract. 
of Med. p. 208. 

Causes. Checked perspiration, by the application of 
cold. Analogy between dysentery and catarrh, found- 
ed on the similarity of their aetiology. Suppressed 
perspiration always among the first morbid phenomena 
of dysentery. Deranged function of the liver and the 
skin are invariably present. (Johnson.) " The period 
most favorable for the production of dysentery, is when 
a cold and moist autumn succeeds a warm and dry 
summer." (O'Brien.) Dysentery appears often to be 
the production of the joint influence of atmospheric 
vicissitudes and marsh miasmata, Sporadic causes, 
such as, unripe fruit; indigestible and unwholesome 
food; irritating substances received into the bowels. 
Not contagious. Scyballa have been much accused 
of giving rise to dysentery; the correctness of this accu- 
sation is denied by Dr. Johnson, and I believe very 
justly. I have seen a very great number of dysenteric 
patients ; and yet the number of cases in which I have 



DYSENTERY. 81 

noticed the discharge of these hardened balls of faeces, 
is exceedingly small. 

Prognosis. Cases in which the stools consist almost en- 
tirely of blood, are generally more tractable than when 
the discharges are principally mucous. Colloquative 
diarrhoea, at an advanced period, very unfavorable; 
stools of a penetrating and cadaverous smell, a very 
bad sign. Tympanitis, with small mucous stools, or 
with fetid sanious discharges from the bowels, highly 
unfavorable. A small, frequent pulse, with a sunken 
and cadaverous countenance, hiccough, and cold ex 
tremities, indicate a fatal termination. Bile appea;^" 
in the stools, is a favorable sign. "7 

Treatment. The indications are — 1. To moderate the 
febrile excitement, when excessive; % To restore the 
functions of the skin and liver ; 3. To subdue the local 
inflammatory affection of the bowels. 

In estimating the comparative importance of these indications, 
it is necessary to recollect, that suppression of the cutaneous 
exhalation, and consequent torpor of the liver, with an engorg- 
ed state of the portal circulation, is antecedent to and causative 
of the intestinal phlogosis, and that the reaction of the heart 
and arteries is consecutivs to this local inflammation. 
From these circumstances, therefore, it seems evident that the 
restoration of the cutaneous and hepatic functions, constitutes 
the most important indication in the treatment of this malady; 
for in proportion as we succeed in the fulfilment of this in- 
dication, so do we equalize the circulation, lessen the determin- 
ation to the bowels, and consequently moderate the local in- 
flammation upon which the peculiar symptoms of the disease 
depend. 

Bleeding . A very important and often indispensable aux- 
iliary remedy, though rarely in itself sufficient to cure 
the disease. Analogy between dysentery and rheu- 
matism, in this respect. Vide Pract. of Med. p. 213. 

Purgatives. Constant and active purgation, injurious; 
mild laxatives, however, should be repeated almost 
daily ; calomel, succeeded by a dose of castor oil; or 
this latter article alone, are excellent laxatives in this 
disease. Purgatives advantageously given in conjunc- 

L 



82 DYSENTERY. 

tion with opium. Spirit, tereb. given with ol. ricini, 
often renders the operation of the latter more certain 
and less painful. (Cheyne.) This is confirmed by 
my own experience. Cream of tartar recommended 
as a purgative. (Cheyne.) Modus Operandi of pur- 
gatives in the cure of dysentery. 

Emetics too much neglected in dysenteiy. Most writers 
recommend tartrate of antimony. I regard ipecacu- 
anha as the best emetic in this disease. Emetics not 
useful or proper in the latter period of the disease; their 

i* beneficial operation confined to its commencement. 

. aiphoretics are among the most valuable curative 
means in this disease. The bowels having been ade- 
quately evacuated by mild laxatives, and bleeding hav- 
ing been practised, where the violence of the febrile 
symptoms demanded, diaphoretics, in conjunction 
with calomel, is the sheet-anchor of our hopes. Do- 
ver's powder, a peculiarly excellent diaphoretic in this 
complaint, on account of its conjoint anodyne and dia- 
phoretic operation. Six grains of this article, with 
three or four grains of calomel, may be given every six 
hours. A combination of calomel, opium, and anti- 
monial powder, an excellent diaphoretic anodyne. 
(O'Brien.) Cullen's objections to opium, in this dis- 
ease, noticed and refuted, Observations on the great 
usefulness of this narcotic in dysentery. 

Dr. Cheyne states, that, in the epidemic dysentery which pre- 
vailed in Ireland a few years ago, he met with many cases in 
which the ordinary plan of treatment by diaphoretics, purga- 
tives, and calomel, made no impression on the disease. These 
cases were attended by intolerance of slight pressure on the ab- 
domen, agonizing pain, unceasing tenesmus, the great pyrexia. 
In these cases, he derived the greatest advantage from opium, 
in four or five grain doses, in conjunction with bleeding, and 
scruple doses of calomel. 

Calomel, with a view to its specific or constitutional ope- 
ration, a valuable remedy in this disease. Ptyalism 
only proper in very protracted or chronic cases. Its 
beneficial operation chiefly dependent on its powers to 



CHRONIC ENTERITIS. 83 

excite the various secreting organs, particularly the li- 
ver, which is always torpid and congested in dysentery ; 
and on its tendency to equalize the circulation. 

Blisters, leeches, or emollient poultices to the abdomen, 
often highly beneficial. 

Anodyne Enemata, relieve the distressing tenesmus and 
tormina. The warm hath is also a very useful auxi- 
liary remedy. 

Balsam capaiva, a valuable medicine in chronic dysen- 
tery. (Pemberton, Cheyne, and Johnson.) 

Astringents may, under certain circumstances, be advan- 
tageously employed ; generally speaking, however, they 
do more harm than good. Other remedies mentioned, 
and their merits discussed. 

CHRONIC ENTERITIS. 

This modification of enteric inflammation, is of frequent 
occurrence. Its symptoms are often obscure and 
equivocal. Most of the cases usually termed maras- 
mus, consist of chronic inflammation of the mucous 
membrane of the bowels. Chronic diarrhoea also ge- 
nerally depends on this grade of internal phlogosis, 
PractofMed. p. 221. 

Symptoms. No distinct abdominal pain; obtuse pain on 
firm pressure on the abdominal parietes; a sense of 
soreness also is felt ; muscular debility ; pulse small and 
weak; cold hands and feet; slight febrile exacerbations 
in the evening; pain in the bowels, or nausea, after tak- 
ing food ; frequently constant diarhoea ; in inveterate 
cases, the skin is dry and sallow; sleep interrupted; 
tongue smooth and red round the edges, and brown in 
the middle; great emaciation; painful diarhoea, alter- 
nating also with costiveness; appetite variable, being 
sometimes voracious, at others entirely Igone ; the food 
is often evacuated from the bowels, in an imperfectly 
digested state ; the alvine evacuations vary in appear- 
ance ; sometimes slimy and small in quantity, at others 



84 CHRONIC ENTERITIS. 

copious, liquid, and dark. The disease continues for 
many months, and even for several years. 

Causes. Sometimes the consequence of acute phlogosis 
of the mucous membrane of the bowels; irritating and 
indigestible food ; the influence of a cold and damp at- 
mosphere; drastic cathartics, and other irritating sub- 
stances, whether received from without, or generated 
in the bowels. 

Treatment. Leeches, or blisters to the abdomen; the 
former are generally thought the most valuable. Al- 
most every thing depends on proper dietetic regulations. 
The food should be of the mildest kind, and " such as 
leaves the least feculence to pass along the intestines." 
A liquid farinaceous diet must be enjoined ; animal 
food, in a solid form, is improper. Barley, rice, oat- 
meal, tapioca, &,c. are to be used in the form of soup, 
or gruel. Over-distention of the stomach, even by the 
mildest food, is highly injurious. Mild laxatives are 
to be occasionally given; active articles of this kind, in- 
jure; castor oil will answer. 

Balsam copaiva, a very valuable remedy. 

Spir. terebinth, given in emulsion, often highly useful. 

It may appear inconsistent to recommend balsam capaiva 
and spirits of turpentine, in this affection after having declar- 
ed that the most unirritating diet is a. sine qua nonon its treat- 
ment, and that active cathartics are injurious, on account of 
the irritation they produce in the phlogosed structure. 

Whatever may' be the conclusions of reason, on this subject, 
experience, which is always our best instructor, teaches, that 
both the articles in question are often decidedly beneficial in 
the present variety of intestinal phlogosis. There is nothing 
more extraordinary in this, than in what is observed in the 
treatment of some other varieties of inflammation. In catar- 
rhal ophthalmia, soothing applications are undoubtedly pro- 
per; yet the application of a weak solution of lunar caustic, or 
of small portions of precipitate ointment, will very frequently 
produce an immediate amendment in the disease, whilst as- 
tringent washes seldom fail to do mischief. 

Opium, with calomel, in small doses. The pulv. ipecac, 
composit; mucilaginous drinks ; and minute doses of 
pulv. ipecac., may be employed with benefit. 



ACUTE PLEURITIS. 85 



CHAPTER XII. 



INFLAMMATION OF THE LUNGS, AND THEIR 
APPENDAGES. 



ACUTE PLEURITIS. 

Symptoms. Pungent pain in the chest, much increased by 
inspiration; cough dry, or attended with a glairy and 
nearly colourless sputa ; pulse full and hard ; difficulty 
of lying on one side ; respiration chiefly performed by 
the abdominal muscles. When the inflammation ex- 
tends to the substance of the lungs, there is generally 
bloody expectoration. 

Causes. Sudden exposure to cold, when the body is in 
a state of free perspiration ; atmospheric vicissitudes ; 
metastases of gout, erysipelas, acute and chronic cuta- 
neous affections, suppressed catamenia, rheumatism. 
It appears sometimes to depend on epidemic causes. 

Autopsic phenomena. The pleura is red, and punctu- 
ated with an infinite number of red points ; frequently 
covered with an immense number of milliary tubercles ; 
false membranes sometimes adherent to its internal 
surface; adhesions between the pleura costalis and 
pleura pulmonalis; occasionally, effusions of sero-puru- 
lent, or serous fluid, into the chest. Pract. of Med. p. 
280. 

Prognosis. Acute pleurisy not a very dangerous disease ; 
its conseqences to be dreaded, in persons predisposed 
to phthisis-, the more the inflammation extends to the 
lungs, the more danger ; the supervention of diarrhsea, 
a fatal sign ; convulsions and coma no less unfavorable. 



80 PERIPNEUMONY. 



PERIPNEUMONY. 



In peripneumony, the inflammation is seated principally 
in the substance of the lungs. It is characterized by 
the following 

Symptoms. Difficult and oppressed breathing ; dull pain 
in the chest; cough, with viscid sputa, mixed frequently 
with blood; pulse at first hard; afterwards weak, soft, 
obstructed, and irregular; inability to lie on the sound 
side; the sputee are of yellowish, or greenish white; 
exceedingly tenacious ; somewhat diaphanous, and in- 
termixed with bubbles of air. (Lsennec.) 

Autopsic phenomena. The structural changes classed 
under three heads. 

1. Engoument, or choked lung. Lungs partially 
crepitous, of a livid color, containing an abun- 
dance of frothy, serous fluid, in its substance. 

2. Hepatized lung. Lungs not crepitous ; resembl- 
ing the liver in weight, consistence, and color, 
having entirely lost its cellular structure, and ac- 
quired a granulated appearance, with no extrava- 
sated fluid in its substance. 

8. Hepatized and granidated structure, with an 
abundance of an opaque, yellowish, viscid mat- 
ter, in its substance. This fluid is the result of 
pulmonary suppuration. (Lseannec.) 
Diagnosis. Peripneumony, distinguished from pleuritis, 

by: (Pract.ofMed.236.) 
Percussion. In peripneumony, the sound of the diseased 
side is obscure, and differs from that produced on the 
sound side, which is more clear. In pleurisy, percus- 
sion produces the same sound on both sides. Pressure 
made on the abdomen, in pleurisy, does not aggravate 
the pleuritic pain; in peripneumony, strong abdominal 
pressure immediately excites distressing involuntary 
cough, oppression, and a sense of suffocation. Posi- 
tion. In pleurisy, the patient lies on the affected side; 



PERIPNEUMONY. 87 

in peripneumony, on the sound side. Pressure on the 
intercostal spaces, produces pain in pleurisy, but not in 
peripneumony ; the pain in the former is lancinating, in 
the latter it is dull. 

Prognosis. Favorable signs: a copious expectoration 
of a thick yellowish matter; increased discharge of 
urine; general, but not profuse perspiration, with an 
abatement of the pain, oppression, and cough. Unfa- 
vorable signs: pain and oppression diffused, dry cough ; 
or thin dark colored expectoration ; countenance livid ; 
great dyspnoea ; weak, soft, and frequent pulse ; deliri- 
um; coma; internal feeling of cold, while the surface 
is hot; a copious and limpid urine in the commence- 
ment; rattling in the chest; disposition to elevate the 
head and shoulders, and bare the breast. 

Treatment. Bleeding ; all important; to be employed 
more cautiously in the advanced periods of peripneu- 
mony, than in pleurisy. Blisters to the thorax, indis- 
pensable ; more efficacious than leeches ; should be early 
applied. Cathartics, of the drastic kind, improper; 
mild laxatives beneficial. Emetics seldom useful. 
Diaphoretics of considerable advantage ; nitre, with 
tart, antimony, commonly employed; muriate ammo- 
nia, instead of nitre, recommended byRichter; I have 
often found it decidedly beneficial. Expectorants very 
useful, after the general febrile excitement has been mo- 
derated^ the mildest and least stimulating articles of 
this class, should at first be used. I have found the 
following a most excellent expectorant, R. extract, gly- 
cyr.: 3Jj. Kermes mineralis, gr. xv. tinct. thebaic, gr. xl. ; 
infus. polygake seneg. 3viii. M. dose, a table-spoonful 
every two hours. Opium, in conjunction with calo- 
mel, a most valuable medicine in peripneumony, after 
the disease has continued three or four days. When 
the expectoration is copious, and of a proper consis- 
tence, opium should be given in very small quantities. 
The pills of Pariset answer a good purpose, under such 
circumstances — they consist of a fourth of a grain of 



©3 PNEUMONIA BILIOSA. 

opium, with a twelfth of a grain of tart, antimony — one 
to be taken every four hours. In pneumonic inflam- 
mation, from repelled cutaneous eruptions, measles, or 
scarlatina, camplwr is, according to Richter, a valua- 
ble remedy — particularly when combined with pulv. 
ipecac, compos. Mucilaginous drinks, &c. 

PNEUMONIA BILIOSA. 

This variety of pneumonia [is produced by the combined 
agency of marsh miasmata, and sudden atmospheric 
vicissitudes. Pract. of Med. 283. 

Symptoms. Along with the ordinary pectoral symptoms 
of pneumonia, there are others, indicative of much 
functional derangement of the hepatic system, such as : 
fulness in the right hypochondrium ; pain in the back 
andUmbs ; yellowness of the tunica albuginea and skin ; 
sometimes mucous and bloody discharges] from the 
bowels, with tenesmus and acute head-ache. These 
symptoms generally precede the occurrence of the 
thoracic affection, for several days. The attending 
fever is somewhat remittent; bilious vomiting is fre- 
quent; tongue covered with a brown for; pulse com- 
monly small, quick, frequent, and slightly tense. 

Treatment. Great discrepancy of opinion on this sub- 
ject; some recommend very copious bleeding — others 
condemn it, and I think with propriety. 

Emetics are of primary importance. Gentle laxatives 
are to be daily employed — for this purpose, calomel, 
with ipecacuanha, answers exceedingly well; from ten 
to fifteen grains of the former, and six or eight grains 
of the latter, generally vomits once or twice, and pro- 
cures several bilious stools afterwards. Blisters less 
serviceable in this than in the preceding varieties of 
pneumonia. Opium, in conjunction with calomel, a 
remedy of great value. Expectorants, useful ; diapho- 
retics of minor consequence. 



ACUTE BRONCHITIS. 89 



ACUTE BRONCHITIS. 



This variety of pulmonary inflammation is generally de- 
scribed under the name of peripneumonia notha. It 
consists of acute inflammation of the mucous mem- 
brane of the bronchia, with great sanguineous con- 
gestion of the lungs. Much of the peculiar charac- 
ter of the disease depends on this congestion. Old 
people and infants most subject to it . 

Symptoms. Great oppression and tightness in the breast ; 
cough; severe pain in the forehead, greatly increased 
by coughing; expectoration; at first, a viscid, and 
frothy white mucus, becoming mixed with blood, as 
the disease advances ; sometimes vomiting ; febrile ex- 
citement not violent; pulse, and heat of the surface, not 
much above the natural standard ; tongue moist and 
white; countenance pallid; little or no pain in the 
chest; the pain is dull, and attended with very oppress- 
ed breathing; vertigo; delirium seldom; wheezing re- 
spiration. 

There is in this disease a particular tendency to effusion 
into the substance of the lungs; and it is generally from 
the occurrence of this circumstance, that the disease 
proves fatal. 

Autopsic phenomena. The lungs do not collapse; 
bronchia filled with a tough mucus, mixed with bloody 
serum and pus ; a frothy fluid escapes from the substance 
of the lungs, when cut into; capillaries of the mucous 
membrane, red and enlarged ; sometimes the pulmon- 
ary structure is more or less hepatized. The mucous 
membrane of the bronchia is manifestly the principal 
and primary seat of the disease. 

Prognostic observations. Ratio Symptomatum. Diag- 
nostic phenomena. 

Treatment. Moderate bleeding, in the commence- 
ment, often beneficial — hazardous, after the disease has 
made some progress ; cathartics of the active kind, in- 

M 



90 CYNANCHE TRACHEALIS. 

jurious — not so, mild aperients. Emetics among the 
most useful remedies, in this disease; they may often 
be advantageously repeated two or three times. Ex- 
pectorants of the stimulating kind, such as polygala 
senega, and gum ammonia, are beneficial. Active 
stimulants must be given with the expectorants, when 
the pulse becomes very small, frequent, and soft. Cam- 
phor, and carbonate of ammonia, are the most valuable 
for this purpose. Opium, less serviceable in this than 
in the preceding varieties of pneumonic disease. In 
the commencement of the disease, small doses of opi- 
um and calomel allay the cough, and promote expecto- 
ration ; but after expectoration is fully established, opi- 
um tends to produce dangerous engorgement of the 
bronchial cells, by allaying the desire to cough, and 
consequently to expectorate the mucus so copiously 
secreted by the bronchial glands. Blisters can never 
be omitted with propriety. 1 have seen much benefit 
derived from large emollient poultices applied to the 
thorax. Diaphoretics^ of the mildly stimulating kind, 
are useful remedies in this disease — such as: infusions 
of eupatorium, sage, balm, the spiritus mindireri, with 
laudanum, pulv. ipecac, compos. &,c. The inhalation 
of the steam of warm vinegar and water. 

CHRONIC PLEURITIS, AND CHRONIC BRONCHITIS. 

As these two varieties of pulmonary inflammation are ge- 
nerally attended with symptoms similar to those which 
occur in phthsis pulmonalis, I shall treat of them un- 
der the general head of Pulmonary Consumption. 

CYNANCHE TRACHEALIS. 

Character. An inflammation of the glottis, larynx, and 
upper part of the trachea, attended with a hoarse and 
ringing cough, sonorous respiration, and a sense of suf- 
focation. 

Symptoms. It commonly comes on gradually: — At 



CYNANCHE TRACHEALIS. 91 

first, a hoarse cough, with slight difficulty of breathing ; 
afterwards fever, respiration becoming more and more 
difficult, each inspiration being attended with a pecu- 
liar ringing sound; countenance full and flushed, 
during the first stage. The dyspnoea becomes at last 
exceedingly great; the head is thrown back, and the 
mouth kept open; the eyes are prominent, and the 
countenance pale, livid, and expressive of great agony ; 
the breathing becomes wheezing, in the latter period of 
the disease ; expiration is quick, inspiration difficult and 
slow; cough sometimes attended with a rattling sound, 
and the expulsion of very tough mucus. Insensibility 
and stupor generally close the scene. The symptoms 
occasionally remit for a short time. 

Causes. Exposure to a cold and damp air, the most 
common cause ; most prevalent in spring and autumn ; 
children between the ages of one and seven years, al- 
most exclusively the subjects of this disease — it very 
rarely occurs in adults. Proximate cause. 

Ratio Symptomatum. The suffocated respiration may 
depend on one or more of the following circumstances : 
— 1. Tumefaction and inflammation of the glottis; 2. 
Obstruction of the glottis by coagulable fluid, in the 
form of a false membrane or a concrete mass; 3. From 
the inflammation extending to the minute ramifications 
of the bronchia, and giving rise to effusion into the air- 
cells. 

Prognosis. The disease is always to be regarded as 
highly dangerous. The more the^inftammation extends 
into the bronchia, the greater the danger. When the 
attack comes on suddenly, with high febrile excitement, 
there is more danger than when its approach is gra- 
dual. Very shrill sounding cough and respiration, un- 
favorable. In general, however, it is difficult to form 
a correct prognosis. Pract. of Med p. 305. 

Spasmodic Croup, essentially distinct from inflammatory 
croup. They may be distinguished by the following 
circumstances — viz. Spasmodic Croup is sudden in 



92 SPASMODIC CROUP. 

its attack, and unattended with fever — Cynache Tra- 
chealis general ly^ comes on gradually; when its at- 
tack is sudden, it is always with fever. In the former 
there are intermissions, in the latter 7'emissions only. 
Cough, with a discharge of viscid mucus from the 
trachea, always present in inflammatory croup — in 
spasmodic croup, coughing is rare and always dry. 
In the latter, no shrillness of voice — the pulse small 
and contracted. 

Treatment. Bleeding, to syncope or an approach to it, 
in the early period, of the utmost importance ; during 
bleeding, the feet should be placed in warm water. 
The advantages of bleeding almost entirely confined to 
the first stage. Emetics next in importance to bleed- 
ing. Calomel, with a small portion of tart, antimon. 
an excellent article for this purpose — preferable, I think, 
to tart, antimon. alone. Emetics often operate with 
great difficulty, after the disease has continued for some 
time — the cause of this explained. The warm foot 
bath, the bleeding, promote this operation. Emetics 
do good, by discharging the viscid mucus from the tra- 
chea, and by equalizing the circulation. Cathartics 
are valuable remedies, in this disease. Calomel is 
the best article for this purpose — large doses, by 
exciting vomiting as well as purging, peculiarly benefi- 
cial. Pract. of Med. p. 306. 

From ten to fifteen grains may be given tc children of from 
two to five years old. This quantity hai-dly ever fails to ex- 
cite active purging and vomiting. The nausea, consequent re- 
laxation produced by calomel, are generally of much longer 
duration than that which is caused by the usual emetics; and 
in general, the impression made on the disease by this medi- 
cine, is much more pei manert than that which results from 
the operation of other emetic and cathartic substances. 

The tincture of lobelia inflata, very useful as an emetic, 
in this disease. Errhines employed with benefit. 

Calomel, with a view to its constitutional influence, high- 
ly recommended by some. Blisters and rubefacients 



CYNANCHE TONSILLARIS. 93 

to the throat, never to be neglected — the latter are pre- 
ferable, from the suddenness of their effects. Spir. tur- 
pentine, with spir. camphor, excites inflammation in a 
few minutes. The warm bath, a very useful auxili- 
ary remedy. Poly gala senaga, useful in slight cases, 
and for the sequalse of violent cases, such as a dry 
and hoarse cough, with slight difficulty of breathing. 

Kali sulfur alum strongly recommended, of late in 
this disease. (Double, Mesner, SenfF, Albers, Ju- 
rine.) 

This remedy does not deserve the praise bestowed upon it 
by some late continental writers. It appears nevertheless, to 
be useful in slight cases, aud is said to be particularly benefi- 
cial only about the period when the exudation of ; the coagula- 
ble fluid occurs. (Raiman.) Our success in the treatment 
of this disease, depends almost wholly on being able to subdue 
the tracheal inflammation before the exudation of the viscid 
mucus takes place ; a vigorously antiphlogistic treatment, in the 
commencement upon which any reliance can be placed. Af- 
ter the exudation has taken place, our principal objects should 
be, to expel the mucus from the trachea before it has time to 
concrete, by the occasional use of emetics. 

The application of a solution of lunar caustic to the upper 
partof the larynx, and about the tonsils, has lately been 
recommended as useful in separating the false mem- 
branes which form in and about the glottis, in this dis- 



CYNANCHE TONSILLARIS. 

Character. Inflammation of the tonsils, soft palate and 
fauces, with synocha fever. 

Symptoms. Tonsils, and soft palate, red and much 
swollen ; deglutition very painful and difficult, — some- 
times impossible; more difficulty in swallowing liquids 
than solids; respiration impeded; speech indistinct; 
hearing dull ; tongue swollen ; white, and covered with 
a thick layer of transparent mucus; pulse full, hard, 
and frequent ; copious secretion of a ropy saliva. 



94 PAROTITIS. 

Cause. Cold and damp air ; or cold in any manner ap- 
plied, so as to cause a sudden check on the perspiration, 
may be regarded as the exclusive cause of this dis- 
ease. Persons become predisposed to the disease, 
by suffering an attack of it. The principal danger 
arises from the swelling of the tonsils, which may pro- 
ceed to the extent of entirely interrupting respiration. 
When it does not end in resolution, it almost always 
terminates in suppuration. Frequent attacks of the dis- 
ease are apt to produce permanent enlargement of the 
tonsils. The inflammation has been known to extend 
into the larynx, in which case the danger is greatly in- 
creased. 

Treatment : strictly and actively antiphlogistic. Scari- 
fying the tonsils; emollient and acidulated gargles; 
warm pediluvium ; blisters and leeches to the throat ; 
emetics ; nauseating doses of antimonials. 

PAROTITIS. 

Character. Inflammation and tumefaction of the parotid 
glands, occasionally epidemic, and manifestly con- 
tagious. 

Symptoms. Hard swelling of one or both parotids — the 
swelling increasing till the fourth day, and then declin- 
ing gradually. Skin over the tumour seldom red or 
inflamed ; the breasts in females, and testicles in males, 
often swell, about the period of the declension of the 
parotid tumefaction; a sudden metastasis often takes 
place from the parotids to these parts. Fever generally 
mild, sometimes violent, 

Children, and young persons are most subject to this dis- 
ease — it rarely occurs in old age. It is most common 
during cold and damp weather. 

Prognosis. Not in general a dangerous affection ; be- 
comes more or less dangerous, by being translated to 
other parts — as the genital organs, the lungs, the brain, 
the stomach. I have known a case terminate fatally 



ACUTE PERITONITIS. 95 

in less than an hour, by metastasis to the brain ; when 
transferred to the testicles, they occasionally suppurate 
— an occurrence always exceedingly painful, and some- 
times fatal. 

Treatment. In mild cases, little more is necessary than 
keeping the bowels open, and using gentle diaphoret- 
ics. The parts should be kept warm — great care 
must be taken, to avoid taking cold . When the in- 
flammatory symptoms are violent, an active antiphlo- 
gistic treatment is necessary. When the swelling dis- 
appears in the neck, and shows itself in the testicles, a 
blister should be laid on the parotids, and every effort 
made to excite a general diaphoresis. To discuss the 
hard swelling which sometimes remains after the in- 
flammatory symptoms have disappeared, frictions on 
the tumour, with mercurial ointment, spirits of camphor, 
or rubifacient liniments, should be used. 



CHAPTER XI. 



ACUTE PEROTINITIS. 



Symptoms. At first, lassitude, pain in the limbs; chills; 
then, head-ache, "a sense of weight in the epigastrium ; 
an acute pain in some part of the abdomen, at first con- 
fined to a small space, but soon extending itself over 
the whole belly : the pain is acute and constant — some- 
times fixed, and at others wandering from one part to 
another. As the disease proceeds, the abdomen be- 
comes tumid, and exceedingly painful to pressure. 
The patient's position is on his back, with the knees 



96 



ACUTE PEROTINITIS. 



and shoulders raised, carefully avoiding all motion of 
his body. The bowels are constipated, and moved 
with much difficulty; pulse commonly small, hard, and 
quick; tongue white and moist, the edges and raphe 
being sometimes very red ; nausea and vomiting, in 
the early stage; the face is generally pallid , exhibiting 
a peculiar sharpness of feature. Constant wakefulness 
throughout the whole course of the disease; delirium, 
except towards the end of fatal cases, rare ; breathing, 
in the latter period , laborious- — inspiration being par- 
ticularly difficult, and attended with an expression of 
pain in the countenance ; suppression of urine, a com- 
mon occurrence. When the disease occurs in the puer- 
peral state, the lochia cease, and the breasts become 
flaccid. Peritonitis is rapid in its course. Pract. of 
Med. p. 226. 

Causes. Mechanical injuries of the abdominal viscera; 
violent and long continued corporeal exertions ; stric- 
ture of the colon and rectum ; extravasations of blood, 
bile, urine, faeces, chyle, &c. into the cavity of the ab- 
domen; the action of cold on the surface of the body ; 
wet and cold feet; drinking cold water, when the body 
is in a state of free perspiration; perspiration; sudden 
suppression of hemorrhoidal discharge of lochia, &,c. 

Prognosis. Favorable symptoms. Abatement of the 
pain. Ability to bear abdominal pressure ; a soft, mo- 
derately full, and not very frequent pulse; moist and 
warm skin; free alvine evacuations; power of changing 
the position, and resting easy on either side; free dis- 
charge of urine; restoration (if in the puerperal state) 
of the lochia; refreshing sleep. Unfavorable signs 
Suppuration, or effusion, is indicated by, diminution of 
abdominal pain; a feeling of weight in the hypogastric 
region ; irregular chills ; coldness of the extremities , 
a soft and feeble pulse. Gangrene, by sudden and en- 
tire cessation of pain; extreme smallness and frequency 
of the pulse, with great prostration ; Hippocratic coun- 
tenance. 



ACUTE TERITONITIS. 97 

Autopsic phenomena. Redness and thickening of the 
peritoneum ; false membranes. A collection of fluid, 
sometimes turbid or whey-like, at others limpid and 
reddish — rarely blood. Adhesions between the bowels 
are common. Gangrenous spots, and red flakes ad- 
hering to the peritoneum. 

The dissections of Broussais, Abercrombie, and others, show, 
that the peritoneum investing the stomach, intestines, liver, 
&c. may be inflamed, and even gangrenous, whilst the struc* 
tures of these organs themselves remain perfectly sound. 

Treatment. Prompt and very copious depletion in the 
commencement, is the principal remediate measure to 
be relied on From thirty to forty ounces of blood, 
drawn soon after the development of the disease, will 
often subdue it so much as to secure a speedy success 
in removing it. The benefit of bleeding is confined 
chiefly to the first twenty-four hours; during this pe- 
riod, the bleeding may be repeated, two, three, or even 
four times, according to the violence of the inflamma- 
tory symptoms. 

Leeching the abdomen, highly beneficial ; after the leech- 
es are removed, emollient poultices or fomentations 
should be applied. 

Purgatives, of the active kind, do much good; they 
should not be given, until decisive bleeding has been 
practised. From the torpor of the bowels, large doses 
are required : the more active the purgative, the more 
good will it do. Calomel, followed by castor oil and 
spirits of turpentine, decidedly the most valuable pur- 
gatives in peritonitis. Calomel and jalap will often an- 
swer. 

After the local and general inflammatory symptoms have 
been somewhat reduced by the foregoing means, opi- 
um, in combination with calomel, is a remedy of great 
efficacy. Cathartics may be effectively employed, at 
the same time that opium is used. Large doses of 
opium in this disease, as in enteritis, promote the ope- 

N 



98 CHRONIC PERITONITIS. 

ration of cathartics. (Armstrong and Johnson.) The 
warm bath, a very useful auxiliary. Blisters to the ab- 
domen, important. Anlimonials seldom admissible, 
on account of the great gastric irritability. If collapse 
ensues, wine and ammonia must be given. Diet of 
the simplest and most unirritating kind. 

CHRONIC PERITONITIS. 

When not the consequence of the acute form of the dis- 
ease, its approach is so gradual and insidious, that it 
rarely becomes the object of medical attention, until 
organic disorder or effusion has taken place. Pract. 
of Med. p. 233. 

Symptoms. A constant feeling of uneasiness in the ab- 
domen, with soreness to pressure, or sudden motions 
of the body, as coughing; sneezing; the skin and ab- 
dominal muscles often lie loosely over the peritoneum, 
giving a sensation to the touch, as if a tight bandage 
were underneath, over which the skin and muscles 
easily slide. (Pemberton.) Sometimes, a sensation 
as of a ball rolling about the abdomen, is experienced. 
(Broussais. ) Pulse rarely affected, except towards the 
evening, when it becomes slightly accelerated. The 
duration of the disease very variable — from a few 
months to several years. Very rarely cured — Brous- 
sais, at first, thought it incurable. It always terminates 
either in effusion or disorganization of the peritoneum 
— most commonly, in both these ways. The effused 
fluid is either serous, limpid, whey-like, or reddish, 
with purulent flakes ; the peritoneum is thickened, or 
covered with an infinite number of milliary tubercles; 
the intestines are often found agglutinated into one 
mass. 

Most cases of incurable Ascites depend on chronic inflamma- 
tion of the peritoneum, and consequent'structural derangement. 
Indeed, it is not improbable, that in all cases of dropsy of the 
abdomen, the peritoneum is in a state of chronic or subacute 
inflammation. Tn treating of Dropsies, this rubjecf will be 
fully. discussed. 



ACUTE HEPATITIS. 99 

Treatment. External vesicating or rubifacient applica- 
tions are of primary importance. Blisters, cupping, 
and frictions with tartar emetic ointment, are the bes ; 
moxa is a powerful agent. Diuretics are recommen- 
ded. Dr. Johnson speaks highly of the following diu- 
retic mixture. R. acid tartar. Gj. Sodse carbon, gr. 
xxiv. Tnfus. digital. 3ss. Spir. nit. dulc. gj. Tinct. 
soillge gtt. iv. Aq. menthae 3jj. m. ft. 1 his draught is 
to be taken two or three times daily. 

Gentle laxatives, such as cream of tartar and acetate of 
potash are to be employed. Small doses of calomel 
and diuretics given conjointly ; diaphoretics also ; par- 
ticularly antimony with minute portions of opium may 
be beneficially employed. 

Perfect rest and quietness are of great importance. 
(Broussais.) Anodynes — particularly hyocyamus, 
and conium maculatum, are serviceable. A simple 
and unirritating diet indispensable. 

ACUTE HEPATITIS. 

Symptoms. Acute pain in the right hypochondrium, 
aggravated by external pressure, and generally by lying 
on the left side; pain in the shoulder and clavicle of the 
right, — sometimes the left side ; commonly a dry cough, 
with difnculy of respiration; nausea and bilious vomit- 
ing ; generally an icteric hue of the albuginea and skin ; 
urine charged with bile; scalding of the urine; thirst 
great; heat of the surface intense; tongue white, or 
covered with a yellowish fur; pulse, hard, full, and 
strong ; bowels costive. In hot climates, acute hepa- 
titis is often attended from the beginning, with small 
liquid and slimy discharges from the bowels. These 
cases are violent and rapid in their progress, although 
the pain in the region of the liver is seldom very great. 
(Johnson.) Delirium more common in hepatitis, than 
in any other of the phlegmasial affections, except 
phrenitis 



100 ACUTE HEPATITIS. 

The symptoms vary according to the part of the liver prin- 
cipally affected ; more pain in the thorax and shoulder 
when the convex surface is inflamed; when the con- 
cave partis the seat of inflammation, there is more gas- 
tric distress, vomiting, aud nausea. Inflammation of 
the interior part, known by the great aggravation of the 
pain, on external pressure. Pract. of Med. p. 238. 

Diagnosis . Distinguished from pleurisy, by the greater 
severity of the cough and dyspnoea in the latter. The 
easiest position in hepatitis, is on the affected side, — in 
pleuritis, on the sound side. In hepatitis, pressure on 
the right hypochondrium aggravates the pain; pressure 
on the intercostal space does not — the reverse obtains 
in pleuritis; often bloody expectoration in pleuritis, — 
in hepatitis seldom if ever. In peripneumonia, as in 
hepatitis, ihe patient lies easiest on the affected side, 
but in the former, respiration is principally performed 
by the abdominal muscles, whereas, in the latter, by the 
intercostal muscles exclusively, The diagnosis be- 
tween hepatitis and gastritis not difficult — the extreme 
prostration — the immediate rejection by the stomach of 
every thing swallowed — the small and tense pulse, &,c. 
which attend gastritis, distinguish it prominently from 
hepatitis. The absence of fever, and the intermitting 
character of the pain, distinguishes spasm of the gall 
ducts, and the passage through them of biliary concre- 
tions, from hepatitis. Pract, of Med. 24"2. 
Hepatitis, if it does not end in resolution, generally ter- 
minates in suppuration. The degree of danger from 
suppuration, depends much on the situation of the ab- 
scess, and the nature of the contiguous parts. When 
the abscess points outwardly, it may be opened by an 
incision, and the matter discharged externally. It 
sometimes breaks into the bowels, the matter being dis- 
charged by stool; occasionally it bursts through the 
diaphragm into the cavity of the thorax, or into the sub- 
stance of the lungs, in which latter case the matter is 
expectorated. Recoveries after this latter accident 



ACUTE HEPATITIS. 101 

exceedingly rare ; always fatal when it bursts into the 
cavity of the abdomen. 

Gangrene an exceedingly rare termination of hepatic in- 
flammation. Doctrines of Saunders and Puchelt con- 
cerning the pathology of acute and chronic hepatic in- 
flammation, introduced and discussed. 

Causes. The influence of cold after profuse perspira- 
tion; violent exercise; contusions of the region of the 
liver; wounds and injuries of the cranium; the irrita- 
tion of biliary concretions ; suppression ofheemorrhois; 
violent rage, or deep sorrow, excessive use of spiritu- 
ous liquors. Dr. Johnson's ciitaneo-hepatic sympa- 
thy, and its application to the aetiology of hepatitis, no- 
ticed. Hepatitis most common in hot climates; solar 
heat and miasmata prominent agents in the production 
of this disease — -they powerfully predispose to, rather 
than excite the disease : heat excites the skin, and mi- 
asmata the liver, to inordinate action ; the cold night 
air checks the former, and consecutively the latter ; fe- 
ver is evolved, and inflammation established in the liver. 

Treatment. Bleeding, both with a view of reducing 
the general inflammatory condition of the system, and, 
by this effect, of promoting the operation of mercurial 
remedies. Bleeding and mercurial purgatives, with 
an epispastic to the right hypochondrium, constitute 
the important remedies during the first few days. Hav- 
ing reduced, by adequate depletory measures, the ge- 
neral ifebrile excitement, our main object must be to 
bring the system under the influence of mercury as 
speedily as possible. Calomel and opium, in combi- 
nation, a very excellent article for this purpose. 

Purgatives of primary importance throughout the whole 
course of this disease; calomel should form a part of 
them. Antimonials, with nitre, useful auxiliaries. 

CHRONIC HEPATITIS. 

Symptoms. Dyspeptic symptoms; countenance sallow 
contracted, and expressive of ill health; dull pain, with 



102 CHRONIC HEPATITIS. 

uneasiness, tension, and sometimes tumefaction in the 
right hypochondrium; bowels irregular, commonly 
costive; sometimes diarrhoea, alternating with costive- 
ness; aching pain in in the right shoulder; urine tinged 
with bile, and voided with a scalding pain; tongue 
white, rather dry ; gums unnaturally hard; a conti- 
nued dryness and- constriction of the skin; difficulty 
of resting easy on the left side; a short and dry cough; 
slight febrile exacerbations, as the disease advances; 
emaciation, and finally, hectic with a puruloid expecto- 
ration. 

Terminations: occasionally in suppuration; more fre- 
quently in induration and enlargement ; sometimes the vo- 
lume of the liver becomes contracted. Though indurated, 
and more firm in its substance than natural, it is often 
specifically lighter than in its healthy state. (Saun- 
ders.) The substance of the liver usually exhibits an 
ash or clay color. 

Causes. Chronic hepatitis sometimes the consequence 
of the acute form of the disease. Most frequently the 
result of the slow operation of the same causes that 
produce acute hepatitis, i. e. the slow and constant ope- 
ration of marsh miasmata, &c. The abuse of spiritu- 
ous liquors, a common cause of chronic hepatitis. 
Protracted dyspepsia produces it. 

Treatment. A strictly antiphlogistic regimen, aided 
by mild aperients, and blisters over the region of the 
liver, are important auxiliary measures for reducing 
slow hepatic inflammation. Without mercury, howev- 
er, these remedies would be of little avail ; it is upon 
this potent medicine that we must principally depend 
for success, in the treatmeut of hepatic inflammation, 
whether of an acute or chronic character. Ptyalism 
must be avoided; the slightest manifestation of the mer- 
curial influence is sufficient. A mild and protracted 
course of mercury will do most good. The nitro-mu- 
riatic acid bath, much extolled by Dr. Scott ; it is un- 
doubtedly a remedy of considerable power in the cure 



NEPHRITIS. 



103 



of chronic hepatitis. The nitric and muriatic acids, 
in ; the proportion of two drachms of each to a gallon 
of water, will make a bath of proper strength. It should 
be heated to the temperature of 96°, and the feet and 
legs immersed in it for half an hour, just before going 
to bed. Pract. of Med. p. 252. 

NEPHRITIS. 

Symptoms. Pain in the renal region ; frequent and small 
discharges of high-coloured urine ; nausea and vomit- 
ing; numbness of the thigh of the affected side; retrac- 
tion of the testicle; pain relieved by bending the body 
forwards or towards the affected side; costiveness ; skin 
hot and dry; pulse full and strong. 

Diagnosis. In inflammation of the psoas muscle, bending 
the body forwards increases the pain ; there is no nau- 
sea and vomiting, nor retraction of the testicles, in this 
affection, as in nephritis. Pract. of Med. p. 245. 

Causes. The influence of cold; mechanical injuries; 
irritating substances absorbed into the circulation, as 
turpentine and cantharides; violent exercise, as jump- 
ing, lifting heavy weights; metastasis of gout and rheu- 
matism ; calculous concretions. 

Unless resolution takes place before the seventh or eighth 
day, suppuration generally ensues. The pus some- 
times discharged with the urine; the suppuration 
often continued for a long time — producing hectic and 
great emaciation, or what has been called tabes re- 
nalis. Sometimes the matter points externally; in 
which case, fistulous openings are apt to remain. A 
puruloid fluid in the urine not to be confounded with 
pus. The former may arise from mere irritation, from 
urinary calculi in the kidneys, or sub-acute inflamma- 
tion of the neck of the bladder. Puruloid matter dis- 
tinguished from pus, by the latter fluid sinking down 
and forming a close layer along the bottom of the ves- 
sel in which the urine is left standing; — puruloid fluid 
remains more or less suspended in the urine. Gan- 



104 CYSTITIS. 

grene a very rare occurrence in renal inflammation. 
Pract. Med. 346. 
Nephritis is apt to leave a predisposition to lithic-acid 
calculi. (Prout.) 

Treatment. Decisive, general, and local bleeding. 
Cupping over the lumber region, particularly benefi- 
cial ; active purgatives required ; much relief obtained 
from emollient enemata, and constant fomentation to 
the regiou of the kidneys; warm bath; sinapisms; 
blisters generally condemned, on account of the ten- 
dency of cantharides to irritate the urinary organs; I 
have found them highly beneficial, and never injurious. 
Anodyne enemata, after the inflammation has been 
somewhat subdued, useful. For the pain and soreness 
left by an attack of nephritis, uva ursi is a valuable re- 
medy — highly useful, also, when suppuration or ulce- 
ration exists. Opium advantageously given with una 
ursi, in nephritic cases; one fourth of a grain of the 
former, with fifteen or twenty grains of the latter, should 
be given thrice daily. Nitre not a proper remedy in 
nephritis. Antimonial diaphoreties beneficial, if the 
stomach will retain them. 

CYSTITIS. 

Symptoms. Severe burning and throbbing pain, with a 
feeling of constriction in the hypogastric region; — pain 
greatly increased by pressure; constant and ineffectual 
desire to pass urine ; pulse, frequent, hard, and full ; skin 
dry and hot; thirst very urgent; great restlessness; 
nausea and frequent vomiting ; slilicidium of the urine ; 
as the disease proceeds, swelling in the loins; rigors; 
cold extremities; delirium, &,c. 

Causes. Mechanical irritation by the presence offoreign 
bodies in the bladder; retained urine; external injuries 
on the hypogastric region; irritation from acrid sub- 
stances absorbed and conveyed to the bladder, as can- 
tharides, turpentine, &,c; metastasis of rheumatism j ir- 



ACUTE RHEUMATISM. 105 

ri taring injections into the urethra; gonorrhoea; sup- 
pressed perspiration, from the sudden application of 
cold. Pract. Med. 353. 
Treatment. Cystitis rapid in its course, and highly dan- 
gerous. The most prompt and decisive depletion is 
necessary ; local bleeding, by leeches or cups, from the 
pubic region and perineum, of great importance ; fomen- 
tations and emollient enemata, efficient auxiliaries ; sin- 
apisms after proper depletion. Internally, opium and 
calomel, in frequent and large doses. (Prout.) Blis- 
ters of doubtful propriety ; bowels to be kept open by 
laxative enemata ; cathartics seldom advantageous ; the 
urine to be drawn off by the catheter, and emollient 
fluids injected into the bladder. Nitre is injuri- 
ous. 



CHAPTER XIV. 

ACUTE RHEUMATISM. 

Character. Inflammation in the fibrous structures about 
the joints, wandering, and attended with severe pain, 
more or less swelling, and synocha fever. 

Symptoms. Chills, alternating with flushes of heat, total 
inappetency, general soreness of the flesh, and lassitude, 
introduce the disease. After some time, usually about 
twenty-four hours, the rheumatic inflammation mani- 
fests itself* One or more joints become swollen, red, 
and extremely painful, the pain being greatly aggra- 
vated by motion; pulse full, hard, and irequent; bowels 
constipated; skin hot, and often covered with profuse 
perspiration; remissions in the morning, and nightly 



106 ACUTE RHEUMATISM. 

exacerbations. The inflammation generally passes 
from joint to joint. The blood is always buffy. 
Rheumatism rare in infancy and old age. Most common 
between . the ages of sixteen and forty-five. Very fat 
persons less subject to it than lean and muscular ones. 
A predisposition to rheumatism sometimes hereditary; 
derangement of the digestive functions sometimes pre- 
disposes to it — so does the excessive use of spirituous 
liquors, and the imprudent use of mercury. Pract. 
Med. p. 370. 
Causes: The influence of variable temperature almost 

the only exciting cause. 
Rheumatic inflammation seated in the fibrous textures 
of the body; essentially distinct from common inflam- 
mation ; shifts its place like gout; metastases to impor- 
tant internal organs, always very dangerous; rarely ter- 
minates in suppuration; never terminates in resolu- 
tion, without the concomitance of general, but not 
profuse, perspiration, and the deposition of a lateri- 
tious sediment by the urine. Neither of these occur- 
rences to be regarded as critical, when they appear 
separately; a very copious sweat is no uncommon oc- 
currence in this disease; but it is never attended by 
any marked abatement of the rheumatic symptoms, 
unless the urine at the same time deposits a red sedi- 
ment. Rheumatism is seldom fatal, except by metas- 
tasis to important internal parts. 
Acute rheumatism, occurring in persons exposed to the 
influence of marsh miasmata, assumes a modified cha- 
racter. There are, in such cases, conjoined with the 
rheumatic affection, prominent symptoms of derange- 
ment of the biliary organs — such as, an icteric hue of 
the tunica albuginea ; a brown and bitter tongue ; great 
head-ache; bilious vomiting, &,c. After each act of 
vomiting, the pains remit. This variety of the disease 
has been called bilious rheumatism. Pract. Med. p. 
371. 
Treatment. Bleeding, an important auxiliary reme- 



ACUTE RHEUMATISM. 107 

dy, though not by itself adequate to subdue rheumatic 
inflammation. Its employment necessary to moderate 
the general and local inflammatory action, and thus to 
prepare the way for the beneficial operation of other 
remedies. Buffy blood, no indication, in this disease, 
for further depletion. Excessive blood-letting favors 
metastasis to internal parts. (Johnson) An early 
translation of the disease to the diaphragm, heart, or 
other internal viscus, demands prompt and copious 
blood-letting, followed by full doses of opium with ca- 
lomel. 

Cathartics always decidedly beneficial ; they often sub- 
duct the general inflammatory excitement more effec- 
tually than bleeding. Calomel, followed by sulphas 
sodte, or sulphas magnesite, the best purgatives. Vio- 
lent purging not proper — being incompatible with that 
regular action of the cutaneous exhalents, which is in- 
dispensable to the removal of this affection. 

Emetics. Recommended by Haygarth and Horn. I 
have known the operation of an emetic to produce im- 
mediate relief of three or four hours' duration. In bilious 
rheumatism, {acute gastric rheumatism of Richter,) 
emetics are, very generally, promptly and decidedly 
beneficial. Tart, antimon. the best emetic. Pract. 
Med. p. 376. 

Sudorifics. Profuse perspiration is seldom beneficial, 
but often injurious. Gentle diaphoresis, however, is 
always serviceable. Antimonials, in small doses, with 
calomel, or pulv. ipecac, compos, so managed as to 
keep up a moderate action of the cutaneous exhalants, 
will assist very materially in subduing the disease. 
Tart antimony, in the proportion of two grains to eight 
ounces of water, given in doses of a table-spoonful ev- 
ery three hours, has been found very efficacious. 

Opium, a valuable remedy under proper management — 
not to be used until the general inflammatory excite- 
ment has been moderated by depletory measures — to 
be used in large doses, conjointly with tarU antim. ca- 



108 ACUTE RHEUMATISM. 

lomel, or ipecac. Large doses have less tendency to 
increase the phlogistic diathesis, than small ones. Af- 
ter proper depletion, three or four grains should be given 
at once. Calomel and opium, particularly valuable : 
two grains of the former, and one of the latter article, 
to be given every three or four hours, until the gums 
become slightly affected. Ptyalism to be avoided. 
In the sub-acute form of the disease, mercury is parti- 
cularly beneficial. 
Colchicum, a very valuable remedy, both in acute and 
chronic rheumatism. The vinous tincture generally 
employed, in doses of from thirty to forty drops every 
four hours, with a small portion of magnesia. 1 have 
known violent cases of the disease yield speedily to this 
remedy. Its effects are to be carefully watched; for 
given in over doses, or continued too long, it produces 
great prostration, violent vomiting and purging, cold 
sweats, syncope, and convulsions. The following for- 
mula for using the colchicum, is recommended by 
Scudamore: R Magnes. calc gr. xx. Sulph. magnes. 
3j. Tinct. co'chici. vinos. 3J. Aq. fontanse, q. s. To 
be taken at once, and repeated every four hours. — 
Pract. Med. p. 379. 
Extract of Stramonium, a powerful and efficacious re- 
medy in acute rheumatism, after the inflammatory 
symptoms have been moderated. (Marcet.) I have 
repeatedly employed it, with signal advantage. It is 
to be used with great caution, on account of its effects 
on the brain — the most singular and violent maniacal 
state of the mind being readily caused by it. Of the 
best extract, a quarter grain is sufficient to begin with, 
to be very gradually increased to one grain, and conti- 
nued till vertigo is produced. 
Local applications. Cold water, applied to the inflamed 
joints, generally gives temporary relief, but has a ten- 
dency to produce sudden translation of the disease to 
internal parts, and consequently to do mischief Scu- 
damore*s liniment, composed of one part of alchohol, 



CHRONIC RHEUMATISM. 109 

with three parts of camphorated mixture, a valuable 
topical remedy. Blisters, after the inflammatory ex- 
citement has been moderated, often decidly advanta- 
geous. Leeching too much neglected — 1 have fre- 
quently known the application of a large number of 
leeches to a joint, procure immediate and permanent 
relief. 
Pressure and tight bandages recommended bv Balfour. 
Observations on this practice — sometimes beneficial, 
in the sub-acute form of the disease. 

CHRONIC RHEUMATISM. 

Symptoms. Little or no swelling, or redness of the parts 
affected ; no fever ; pain sometimes confined to one or 
two joints — sometimes felt only on motion. In some 
instances, the rheumatic form is persistive ; in others, af- 
ter having continued for a time, it goes off, leaving the 
parts somewhat stiff and debilitated. The skin is gene- 
rally dry and harsh. 

Sequela. A thickened and knotty state of the tendons ; 
hardness of the bursse mucosae ; wasting of the muscles 
about the affected joints; rigidity and thickening of the 
ligaments, and consequent stiffness of the joints, are con- 
sequences of severe and protracted rheumatism. 

Diagnosis. Chronic rheumatism in the muscles of the 
loins, (lumbago,) distinguished from nephritis by the 
aggravation of pain on bending, the body forwards, as 
well as by the absence of nausea and vomiting, retrac- 
tion of the testicle, and urgent desire to pass urine, which 
characterize the latter complaint. 

Mercurial or syphilitic rheumatism, distinguished from 
rheumatism produced by other causes, by the perios- 
teum of the tibise, ulnse or os frontis, becoming thicken- 
ed and tender to pressure, together with the history of 
the case. 

Causes. Frequently the result of the acute form of the 
disease ; continued exposure to a damp and cold atmos- 



110 CHRONIC RHEUMATISM. 

phere; improper exposure, while under the influence 
of mercury ; atmospheric vicissitudes. 

Treatment. Though not generally indicated, bleeding 
is proper as a preliminary measure in robust and ple- 
thoric subjects. 

Sudorifics are useless. 

Diaphoretics are beneficial. G. guaiacum much recom- 
mended ; best adapted to cases occurring in subjects of 
a relaxed or phlegmatic habit of body, and in old peo- 
ple. In young, vigorous, and plethoric subjects, it 
rarely does good, and sometimes harm. 

Antimony, a useful article in this disease. I have deriv- 
ed much advantage from its use, in conjunction with 
infusion of the root of burdock, (arctium lappa. ) A 
grain of tart, antim. disolved in a pint of strong infusion 
of this root, should be taken daily. 

Mercury, much recommended for its powers in this dis- 
ease particularly useful, when the disease arises 
from cold, while the system is under, the influ- 
ence of mercury — the usual diaphoretic decoctions 
advantageously used along with it. I have derived 
much advantage from mercury, conjointly with the fol- 
lowing decoction : R.Rad. sarsaparil . 3jjj. Fol. chyma- 
phyl, 3jss. Rad. mezer, 3jj. Cort. ulm. fulv. sj. Aq. bul- 
lient. fejjj. To be boiled down to three half pints. Dose, 
a wine-glass-full, four times daily. Dr. Otto, of this city, 
states that he has seldom been disappointed in curing 
the disease by salivation, continued for three or four 
weeks. Calomel and opium. 

Stramonium, an efficacious remedy in this form of the 
disease. Scudamore speaks highly of extract of stra- 
monium and lactucarium, in combination — a quarter 
grain of the former, with two grains of the latter may 
be given every four hours. 

Colchicum,. iio less usefulin this, than in acute rheuma- 
tism. 

Spirits of turpentine, much and deservedly recommend- 
ed, particularly when it is seated in the hips or loins. 



GOUT, 111 

(Home.) Dose, from twenty to forty drops, thrice dai- 
ly- 
Phytolacca decandra. The tincture of the berries has 

been used with advantage. ZanthoxyVwm fraxine- 
um. 

Solarium dulcamara, in recent cases from suppressed 
perspiration. 

Hyoscyamus. The extract a valuable palliative, in pain- 
ful inveterate cases. 

Compression by the tourniquet — acupunctuation— elec- 
tricity — galvanism, have all been employed , with de- 
cided benefit. Exercise of the whole body, to a d&- 
gree sufficient to excite perspirations, has performed re- 
markable cures. Rubifacients. 

GOUT. 

Gout is divided into the acute, the chronic, and the re- 
trocedent varieties. Pract. Med. p. 386. 

Symptoms. Of the acute form. Violent inflammation 
of the ball of the great toe of one foot, attended with 
excruciating pain, redness of the skin, distention of the 
neighboring veins, and, at the end of about forty-eight 
hours, oedema. The attack generally occurs between 
12 and three o'clock at night. There are slight remis- 
sions in the morning, and violent exacerbations at 
night. The paroxysm seldom terminates before the 
sixth, or continues beyond the tenth day. The cedema 
contines some days after the inflammation has subsided. 
After the disease has disappeared in one foot, it some- 
times makes an immediate attack on the other. The 
disease is generally preceded by a train of premonitory 
symptoms, most commonly indicative of gastric dis- 
order. 

Though in its first attacks confined exclusively to the? 
feet, gout seizes upon many other parts, during the 
same paroxysm, after the system has become enfeebled 
by frequent recurrences of the disease. Pulse, in se~ 



112 



GOUT. 



vere attacks, fall, hard, and strong ; in slight cases, the 
constitutional symptoms not prominent; the digestive 
functions always considerably disturbed ; bowels tor- 
pid ; urine scanty, and of a deep red color, depositing 
a pink or lateritious sediment. The inflamed parts are 
exquisitely sensible to the slightest touch. 

Sequela. Frequently, structural derangement of the li- 
ver; permanent debility of the stomach. Thickening 
and shortening of the ligaments, and distention and in- 
duration of the bursee mucosae, are the most common 
local consequences of gouty inflammation. Gouty con- 
cretions not very frequent. 

Predisposition. The predisposition to gout sometimes 
hereditary, though not so frequently as is generally 
supposed. It is most commonly acquired, by the ope- 
ration of the following, and perhaps other causes — viz. 
the depressing passions, severe and protracted study; 
the habitual use of high-seasoned animal food and vi- 
nous liquors, with an indolent or inactive course of 
life. 

Gout rarely occurs before the 20th year of age — most 
apt to commence its attacks between the 30th and 40th 
years. 

Exciting causes. Excessive intemperance ; — redundan- 
cy of bile; an accumulation of acid in the stomach; 
cold and humidity; external injuries; fatigue, and men- 
tal anxiety ; violent passions. Pract. Med. p. 392. 

Proximate cause. Some writers regard the proximate 
cause of gout to consist in an excess of the elements 
of uric acid, (Brandt, Home,) and others, in an excess 
of phosphoric acid* (Berlholet,) Scudamore's objec- 
tions to these doctrines, stated and assented to. Debi- 
lity and disorder of the digestive organs, has been re- 
garded as the proximate cause of gout: — objections 
stated to this doctrine. According to Bioussais, the 
proximate cause of the disease consists in a peculiar 
irritation of the mucous membrane of the alimentary 
canal. I think it not improbable that derangement of 



GOUT. 113 

the assimilative functions, with general plethora, in 
conjunction with snch a peculiar irritation in the ali- 
mentary canal, constitutes the fundamental pathologi- 
cal condition of gout. Pract. Med. p. 394. 

Treatment. To obviate the recurrence of the disease, 
we must remove, as much as possible, the predisposing 
and exciting causes, and restore the healthy action of 
the digestive organs. A simple and digestible diet must 
be enjoined, and the use of wine and condiments inter- 
dicted. The occasional use of mild aperients, and 
some of the bitter tonics, is proper. 

The treatment during the paroxysm. Bleeding, though 
highly recommended by some, is not in general a re- 
medy of much importance in the paroxysm of gout, ex- 
cept when it is suddenly translated to the brain. Copi- 
ous bleeding favors metastasis. Emetics proper only 
when the stomach is surcharged with indigestible ali- 
ment. 

Cathartics and diuretics are decidedly beneficial, in the 
treatment of gout. Two or three evacuations should 
be procured daily . Calomel, with rhubarb , an excel- 
lent purgative in this disease. Scudamore recom- 
mends the following cathartic: R. Extract, colocynth. 
compos. 3ss. Calomel, gr. xv. Tart, antim. gr. i. M. 
Divide into 16 pills. Dose, two or three in the evening. 
Diuretics and purgatives, exhibited conjointly, partic- 
ularly useful. Thus: B. Magnes. calc. gr. xx. Sul- 
phat. magnes. 3jss. Vini . colchici. 3jss. Aq. fontan. q. s. 
To be taken at once, and repeated every four or five 
hours. (Scudamore.) I have found this mode of ex- 
hibiting diuretics and purgatives in union, highly bene- 
ficial. • 

Colchicum — the ancient hermodactylus, a remedy of 
great powers in this disease. It seldom fails to cure 
the local symptoms speedily; but, according to some 
writers, it leaves the disposition to the disease much 
stronger, and leads more rapidly to the chronic form. 
I think it - probable, that these evil consequences are 
p 



114 GOUT. 

the result of the improper or inordinate use of this ar- 
ticle, and that under judicious management, it is as 
safe as it is valuable. The latest and best authorities 
on this subject, recommend it to be given in conjunction 
with magnesia. 

Eau medicinale, a celebrated French nostrum. The 
tincture of while hellebore, and laudanum, &,c. 

Opium is a valuable palliative in cases attended with 
extreme pain. It should be freely administered ; one 
grain every hour or two, until the pain remits; it ren- 
ders the pulse softer and less frequent, causes a gentle 
diaphoresis, and tranquillizes the nervous system. Its 
modus operandi explained. 

Local remedies. Leeches increase rather than diminish 
the pain ; blisters not useful, except to recal the disease 
to the extremities, when it has passed on to more im- 
portant parts by metastasis; warmth, by the applica- 
tion of flannel or cotton, an old and popular practice, 
though attended with no advantages. Cold • applica- 
tions will speedily relieve the pain, but are apt to pro- 
duce dangerous metastasis. Evaporating lotions, of 
a stimulating character, are frequently beneficial. 

Treatment proper during convalescence. After slight 
attacks, and before the constitution has suffered much, 
little or nothing need be done during convalescence. 
But in violent and protracted cases — particularly after 
repeated attacks have impaired the constitution, medi- 
cal treatment during convalescence is of the greatest 
consequence. In cases of this kind, it is necessary to 
restore the energies of the digestive organs, as well as 
of the liver, skin, and kidneys. For this purpose, 
small doses of blue pill, with the occasional use of rhu- 
barb and magnesia, and a weak infusion of colomba, 
&c., in general answer very .well. Gentle exercise also 
must be enjoined. The application of a flannel roller 
to the affected parts, highly useful, when permanent 
swelling and debility remain. 
Chronic Gout. A strong gouty diathesis, without suffi- 



GOUT. 1 1 5 

cient constitutional vigour to produce high inflamma- 
tory affection of the joints. It is characterized by pro- 
minent and harassing symptoms of dyspepsia; irritabi- 
bility of temper, and despondency and irresoluteness of 
mind; palpitations, with a sense of tightness at the pit 
of the stomach ; cramps in the extremities, particularly 
at night; dull pain in some of the joints, attended with 
a sense of numbness and weight in the affected part; 
sleep unsound, and interrupted by sudden startings; 
permanent oedema left in the affected parts ; tenderness 
and aching of the ancles, rendering progression diffi- 
cult and painful ; skin sallow, dry, and contracted ; 
bowels costive, and in very bad cases much general 
debility, wasting of the flesh of the lower extremities, 
a dry and short cough, &c. 
Treatment. The principal indications in the treatment 
of this form of gout are ; to strengthen the system in 
general, and the stomach in particular* For this 
purpose, a mild and digestible diet, with gentle exer- 
cise, cold bathing, mild aperients, and the occasional 
use of the mercurial alterative pill, are our most useful 
remediale measures. To relieve the distressing ner- 
vous irritation, opium, lactucarium, stramonium, or 
hyoscyamus, are to be occasionally used. 1 have found 
a combination of opium, camphor, and nitre, an excel- 
lent anodyne in such cases. Tonics seldom service- 
able. Pract. Med. p. 395. 
Retrocedent^Gout. The disease is called retrocedent, 
when the inflammatory affection of the joints suddenly 
and entirely Ceases, at the same time that some internal 
part becomes affected. The part to which' it is most 
apt to be transferred, is the stomach; sometimes it falls 
upon the lungs, &t others the brain, and occasionally 
the heart becomes its seat. When the ^stomach, in- 
tense pain, anxiety, nausea, and vomiting, occur; when 
to the lungs, asthmatic symptoms supervene; when 
the heart becomes affected, pain in the cardiac region, 
with violent palpitation and syncope, ensue ; metastasis 



1 J 6 SMALL-POX. 

to the brain, produces insensibility, coma, apoplexy, or 
palsy. Any of these translations of the disease, are ex- 
ceedingly dangerous. 
Metastasis to internal organs most commonly produced 
by the application of cold to the inflamed joint; any 
thing which rapidly debilitates the system, as bleeding, 
violent purging, sudden fright, &,c, may cause metas- 
tasis. 

Treatment. When the disease attacks the stomach, 
warm brandy, or laudanum joined with aromatics, 
must be freely administered, and a sinapism laid over 
the epigastrium. Opiates, antispasmodics, and sina- 
pisms or blisters to the chest, when the lungs are af- 
fected. Metastasis to the brain, to be treated by prompt 
and copious bleeding, cold applications to the head, 
sinapisms to the feet, and stimulating purgative enemata. 

The gouty diathesis predisposes to: apoplexy, asthma, 
hydrothorax, ascites, erysipelas. 



CHAPTER XV. 



EXANTHEMATA. 



SMALL-POX. 



Small pox is divided into two varieties, the confluent and 
distinct. The distinctive character of the former is: 
pustules confluent, depressed, irregularly circumscribed, 
the intervening spaces being pale, and the fever conti- 
nuing after the eruption is completed . The distinctive 
character of the latter is: pustules distinct, elevated, 



SMALL-POX. I 17 

distended, circular; the intervening spaces being red, 
and the fever ceasing, when the eruption is completed. 

Description of the distinct [land. At first aching pain 
in the back and lower extremities, lassitude and loss of 
appetite, slight chills, nausea and vomiting, with some 
soreness in the fauces, and finally, fever. Towards the 
end of the third day of the fever, the eruption makes 
its appearance, first on the face and neck, and succes- 
sively on the inferior parts. 

Just before the r eruption appears, adults generally per- 
spire freely; and sometimes become comatose. Chil- 
dren frequently suffer convulsions at this period; the 
fever ceases by the fifth day. At first the eruption con- 
sists of small red spots, rising, by degrees, into pimples, 
then becoming vesicular on the top, with a small pit 
in the centre, and finally about the eighth day, becom- 
ing pustular, and of a spheroidal shape. About this 
period, the face and eye-lids swell ; the tumefaction 
subsiding again about the eleventh day. The pustules 
are at their i full and perfect state on the twelfth day; 
from this date they begin to shrink and dry, the matter 
forming crusts of a brown colour; in a few days more, 
these crusts fall off, leaving the skin underneath of a 
brownish red color. 

The pustules are surrounded by an areola, of a damask- 
rose color. When the pustules are numerous, some 
degree of fever occurs on the tenth or eleventh day. 
In these cases, there is usually some soreness of the 
throat, hoarseness, and a copious discharge of a thin 
fluid from the mouth. The eruptive fever is of the 
synochus, and not unfrequently of the synocha grade. 

The confluent variety. In this variety, all the above- 
mentioned symptoms of the early stage are severer. 
The accompanying fever at first synocha, then typhoid ; 
pain in the loins, in the forming stage very severe; the 
severer thisjpain, the more certainly will the disease 
assume the confluent character. (Richter.) Seldom 
any profuse perspiration just before the appearance of 



118 SMALL-POX. 

the eruption, as in the distinct kind ; instead of this, 
dittrrhcea often occurs at this period. Great soreness 
and redness of the fauces, and generally a copious flow 
of saliva. The pustules appear earlier than in the dis- 
tinct kind — seldom later than the beginning of the third 
day — very rarely as late as the fourth or fifth day. 
The pustules not surrounded by an inflamed margin, 
where they are separated — the intervening skin re- 
maining pale and flaccid; the face is always much 
swollen — the swelling coming on earlier than in the 
distinct variety, and declining about the tenth day. 
The matter in the pustules is never thick and yellow, 
as in the distinct variety; but of a whitish brown, and 
sometimes dark color. 
About the eleventh day, the pustules break, and pour out 
a fluid which hardens into brown or black crusts. 
When these fall off, the skin underneath desquamates, 
producing small and permanent depressions, or pits, 
in the skin. The fever does not cease, but remits on 
the appearance of the eruption, increasing again about 
the sixth day, and continuing throughout the whole 
course of the disease. 

The regular course of small-pox includes therefore four 
distinct stages, viz: 1st. The eruptive fever, including 
a period of from two to four days days: 2d. The pe- 
riod of eruption, of about two days continuance: 3d. 
The period of maturation, or filling, which occupies 
about three days: 4th. The period of exsiccation, or 
drying of the pustules, which terminates about the fif- 
teenth day from the commencement of the disease. 

Chrystalline small-pox. In this variety, the fluid in 
the pustules is colorless, having no purulent appear- 
ance. The pustules, though not confluent, are never 
surrounded by a florid areola; the swelling of the face 
is often suddenly transferred to the hands and feet; 
fever typhoid ; pustules, pale or lead-colored. 

Small pox often remarkably modified by the influence of 



SMALL-POX. 119 

the contagion of measles. These two diseases cannot 
go on at one and at the same time, in the same system. 
Hunter's doctrine of the incompatibility of two kinds 
of morbid action, referred to. Its applicability to the 
explanation of the] modus operandi of medicines, in 
the cure of diseases. Remarks on the power of this, 
and other forms of exanthematous diseases, of destroy- 
ing the susceptibility of the system to a second infection. 
Autopsic phenomena. In violent cases, pustules in the 
larynx, trachea, and bronchia, inflammation of the 
mucous membrane of the alimentary canal, is inva- 
riably found. 

Prognosis. The more the disease retains the distinct 
form, the safer. The confluent form, always danger- 
ous ; and the danger is greater, according as the fever 
assumes more of a typhous character. 

Observations on the origin of small-pox. The opinion 
maintained, that the disease often originates spontan- 
eously without the immediate agency of contagion. 

Treatment. The heating plan of treatment, pursued 
formerly, did much injury. An anti-phlogistic treat- 
ment is all-important; by moderating the eruptive fever, 
the eruption is rendered more scanty; and the whole 
disease, consequently, more mild. Moderate bleeding 
should be practised, when the febrile excitement is 
violent ; copious bleeding being very rarely demanded. 
Mild cathartics, highly useful through the whole course 
of the eruptive fever. Violent purging improper, in 
the distinct variety of the disease, — not so in the more 
malignant and confluent kind, where they will often do 
much good. (Mead, Friend, Cleghorn, Huxham.) 

The supervention of a spontaneous diarrhoea, in the early stage 
of confluent small-pox, is almost always followed by a less nu- 
merous crop of pustules, and by an abatement of the febrile 
excitement, and of the swelling of the face and hands. 

Calomel is the best purgative in small-pox; many main- 



120 SMALL-POX. 

tain that it possesses a peculiar power of moderating 
the violence of the disease. 

Emetics, sometimes useful in the beginning of the disease, 
particularly in the confluent variety. 

Diaphoretics, of the refrigerant class, are beneficial, as 
nitre, antimonials, saline draught, spir. mindereri. 

Cool air. The free admission of cool air into the apart- 
ments of small-pox patients, together with the use of 
cooling acidulated drinks, light and cool coverings, 
is one of the most important improvements in medicine 
that has ever been made. The patient should be laid 
on a mattress, and the temperature of his apartment so 
regulated, as to communicate to him rather a sensation 
of coolness than warmth. 

When the eruption of the confluent variety of the disease 
is attended by fever of a typhous grade — which is some- 
times, though rarely, the case, the diet, instead of being 
cooling and diluent, must be stimulating and nourish- 
ing. Wine, here, is a very useful remedy; the carbo- 
nate of ammonia also answers well. When delirium 
attends a weak grade of reaction in this disease, cam- 
phor is the best stimulant. Cinchona, a valuable re- 
medy during the suppurative stage of confluent small- 
pox, with typhoid fever. Opium, in combination with 
camphor, very beneficial, when the pustules are slow 
in filling up, or the fluid in them remains watery . — 
Warm fomentations to the feet, and leeches or blisters 
to the scalp, useful, when the brain becomes much af- 
fected. Diarrhoea, in the secondary fever of conflu- 
ent small-pox, is unfavorable, and must be checked by 
prepared chalk, suspended in some astringent vegetable 
infusion. Opium and camphor, an effectual means of 
checking obstinate vomiting — an occurrence always 
dangerous in small-pox. Epileptic convulsions, just 
before the eruption, not particularly dangerous in dis- 
tinct small pox — more dangerous in the confluent va- 
riety. 

The use of lunar caustic, as a local application to the 



VARIOLA VACCINA. 121 

pustules, has of late been recommended and success- 
fully practised, in France, for the purpose of lessening 
the number of pustules, and by so doing, rendering the 
disease milder and less dangerous. 
Cauterization of the pustules, on the first or second 
day, will destroy them. 

In 1825, M. Velpeau read a memoir before the Royal Acade- 
my of Medicine, of Paris, tending to prove, that, if the pustules 
of small-pox are cauterized, during the first two days, with lu- 
nar caustic, the progress of the pustules will be arrested. This 
practice was fully tested some time after, by Dr. Meyreux. 
According to his report, it appears, that if the variolous pus- 
tules are opened with a lancet, and touched with a pointed piece 
of lunar caustic, on the first or second day of their appearance, 
they will be wholly destroyed, and leave no marks j but on the 
third day, it will be quite useless. 

VARIOLA VACCINA. 

Origin of the disease. The vaccine matter, originally 
obtained from a pustular disease affecting the udders 
of cows — hence its name. The grease of horses, and 
cow-pox, were, at first, thought the same disease ; and 
this opinion is strongly supported by the experiments 
of Mr. Ring, Friese, Loy, and Sacco ; they having pro- 
duced genuine cow-pox, both in the vaccine and hu- 
man systems, by the matter of grease. Dr. Jenner 
could not communicate the vaccine disease to a person 
who had previously been affected by the disease pro- 
duced by the grease. Matter taken from a peculiar 
pustular disease, which occurs about the head and nose 
of sheep, will, according to Richter, Sacco and others, 
produce a pustular affection in the human subject, si- 
milar to cow-pox, and capable, it is said, of destroying 
the susceptibility to the subsequent influence of the va- 
riolous contagion. 

Description. The vaccine disease can only be commu- 
nicated by inoculation, or by bringing the virus in im- 
mediate contact with a part denuded of the cuticle. 
The matter being inserted under the cuticle, the pus- 
Q 



123 VARIOLA VACCINA. 

tule commences and proceeds in the following manner: 
— on the second day a small point; on the third day 
more distinct; on the fourth day slightly elevaed like 
a small pimple, and surrounded wiih a narrow and 
faint areola; on the fifth day more elevated, vesicular, 
circular, its surface flattened, with a small dark depres- 
sion in its centre, containing a colorless fluid ; on the 
ninth day the pustule is in its full state of perfection, 
the areola being large and of a beautiful damask-rose 
color; at this period, slight constitutional symptoms ge- 
nerally occur. The areola efflorescence not essential 
to the protecting power of the disease. On the eleventh 
or twelfth day the centre of the pustule becomes dark- 
er, which gradually extends to the circumference, so 
that a brown scab is formed by the fourteenth day. 
The scab becomes darker until it acquires a dark ma- 
hogany color, and in five or six days more falls off. 
There is seldom more than one pustule; instances of 
several, and even numerous pustules, have, however, 
occurred. 

The vaccine disease often subdues other affections ; crus- 
ta lactea, scrofulous swellings, ophthalmia, whooping 
cough, have yielded permanently to the influence of 
this disease. 

Herprtic aud other cutaneous affections, may occasion 
such a deviation in the vaccine pustule, from its genu- 
ine character and course, as to render it ineffectual as 
a preventive of small-pox. Diseases of the skin, from 
which a fluid exudes, capable of conversion into a 
scab, ore particularly apt to disturb the specific charac- 
ter of the vaccine disease. 

Measles and cow-pox may go on simultaneously in the 
same person. 

Diagnosis, between the spurious and genuine disease. 
In the spurious, the point of inoculation is already con- 
siderably inflamed and elevated on the second day; on 
the fourth or fifth day, an irregularly defined efflores- 
cence appears, and scabbing is completed as early as 



VARIOLOID. 123 

the seventh or eighth day; the pustule is irregular or 
angulated in its circumference, and without a depres- 
sion in its centre. 

The spurious disease may be produced by, 1. The ex- 
istence of some cutaneous affection in the vaccinated 
patient; 2. Matter taken from a spurious pustule; and, 
3. Matter that has suffered some change by long 
keeping. 

The matter should be taken from the pustule for vaccina- 
tion, between the seventh and ninth day. The scab is 
generally used for vaccination. 

Appearance of the genuine scab. Smooth, dark-brown, 
rather brittle than tenacious, and of a regular circum- 
ference. 

In taking either matter or the scab for vaccination, it is of the 
utmost importance to be well assured that tbe person from 
whom it is taken is healthy; and particularly that he was not 
affected with any other cutaneous disease, during the progress 
of the vaccine infection. 

General remedial treatment, very rarely necessary. 
Local applications, such as cold water, a weak solution 
of sugar of lead, emollient poultices, to moderate the 
local inflammation, are sometimes required. 

The prophylactic power of the vaccine disease dismissed. 

VARIOLOID. 

Some regard this disease as sui generis; others, and with 
correctness, I think, consider it as small-pox modi- 
fied, by the system having previously undergone the 
vaccine, or some other modifying influence. Varioloid, 
or modified small-pox, is no new disease, — having been 

' observed and described for centuries past, under the 
different names of chicken-pox, horn-pox, swine-pox, 
&/C Proofs adduced of the variolous origin of this 
disease. The most conclusive of which is, that mat- 
ter taken from a varioloid pustule, has produced ge- 
nuine small-pox. 



124 TARIOLOID. 

Description. This disease varies exceedingly in its ap- 
pearances, course, and degrees of violence. The 
eruptive fever is generally very mild, and of irregular 
continuance, varying from two to five days; a roseolous 
rash often precedes the eruption. (Thomson.) At 
first, small papulae appear, some of which soon dry off, 
the others change to vesicles containing a thin limpid 
fluid, as early as the first or second day; generally 
about the third or fourth day, these vesicles burst or 
decay; frequently, small areola surround the vesicles. 
This is the mildest form of the disease, and is scarcely 
distinguishable from chicken-pox. Sometimes the erup- 
tive fever is violent; the eruption having more the cha- 
racter of pustules with slight central depressions, re- 
maining five or six days before they begin to dry off. 
Occasionally the scabs do not fall off until the ninth, 
tenth or twelfth day. 

The following circumstances constitute the prominent 
and characteristic features of the disease: — 

1. The eruption appears in successive clusters, and 
at uncertain periods after the beginning of the fever. 

2. The vesicles seldom if ever enter into complete 
suppuration. 

3. There is no secondary fever. 

4. The drying off or scabbing occurs generally be- 
tween the fifth and seventh day ; the scabs falling 
off as early as the eighth or ninth day. 

5. They leave no pits, but red disks or elevations. 
It is pretty certain, from recent observations, that the va- 
riolous contagion does occasionally operate on the sys- 
tem, and produce varioloid disease, even after the most 
perfect vaccination. This, however, is not often the 
case; and the frequency of this disease (varioloid) must 
be, in a great measure, ascribed to the previous vacci- 
nation having been rendered imperfect, by one or more 
of the following circumstances: — 

1. Pre-occupation of the skin by herpes or some other 
cutaneous disease. 



RUBEOLA. 125 

2. Vaccination with spurious matter. 

3. Depriving the vaccine pustule incautiously of its 
contents. 

4. Injury done to the vesicle in its early stage. 

In relation to the character of the cicatrix, Dr. Gregory makes 
the following observations. " It would be improper to over- 
look the remarkable connexion that subsists between the degree 
of perfection in the vaccine cicatrix, and the violence of the se- 
condary disease, (varioloid.) When the scar on the arm is 
perfect, that is, distinct, circular, radiated, and cellulated — but 
above all, when it is small, so that it may be covered with a 
split pea, the secondary affection (varioloid,) will be slight, 
and hardly deserve the name of a disease. On the other hand, 
whenever the scar is large, and bears the marks of having been 
formed by high local inflammation, and wants the other distinc- 
tive characters just mentioned, the chance of having secondary 
small-pox in after life, will be greater, and, cceteribus paribus, 
there will be a stronger likelihood of its proving severe." 



VARICELLA CHICKEN-POX. 

Description. Little or no eruptive fever; the eruption 
consisting of transparent pea-sized vesicles, coming 
out in successive crops, bursting at the top about the 
third day, and concreting into thin brown crusts by the 
fifth day — leaving no scar when they fall off. 

Medical treatment rarely necessary. 

Are small-pox and chicken-pox produced by the same 
virus, as has been, and is still, by many, supposed? 

RUBEOLA MEASLES. 

Description. The disease frequently commences with 
the symptoms of common catarrh — namely, lassitude, 
slight chills, sneezing, watery and slightly red eyes, 
cough, and some degree of hoarseness. More com- 
monly, however, the catarrhal symptoms do not super- 
vene, until the fever is fully developed. The fever is 
often mild ; sometimes it is violent from the commence- 
ment. The skin is hot and dry, the tongue white and 



126 RUBEOLA. 

punctuated with prominent red points. About the 
fourth clay of the fever, the eruption appear?, first on 
the face, extending gradually down over the whole 
body. Nausea and vomiting, and sometimes slight de- 
lirium, and even coma in violent cases, occur shortly 
before the appearance of the eruption. On the sixth 
day, the eruption begins to fade on the face, but not on 
the rest of the body; but on the seventh day, it begins 
to become paler on the other parts, except on the backs 
of the hands, where it remains vivid until the eighth 
day. About the ninth day, the eruption presents a 
faint yellowish appearance, and desquamation begins 
on the face, which, in two days more, is completed over 
the whole body. Occasionally, the eruption comes out 
as early as the second day, and sometimes, though 
very rarely, as late as the seventh day. The eruption 
is not uniform, buc forms irregular patches, approach- 
ing the semi-circular or crescent shape. (Willan.) 
Commonly, the face swells considerably during the height 
of the eruption. The fever does not abate on the ap- 
pearance of the eruption^ but, on the contrary, in- 
creases. The catarrhal symptoms, also, increase in 
violence. Diarrha-a often comes on about the time 
the eruption declines, which, when not excessive, is fa- 
vorable. The fever almost always declines pari passu 
with the desquamation; in some instances, however, 
though rarely, it continues and even becomes more 
alarming after this period. There is a very strong 
tendency to pectoral inflammation in this disease. — 
Pneumonia and croup, most apt to occur about the 
drae the eruption begins to decline. Ear-ache, inflam- 
mation and swelling of the eyelids ; swelling of the 
glands about the neck ; herpes, porriginous pustules, 
tumid lip, serous discharges from behind the ears, and 
tedious suppurations, are among the sequelae of the 
disease. These consequences are generally the result 
of improper management — particularly of incautious 
exposure to cold and damp air, and sometimes of con- 



RUBEOLA. 127 

stitutional predisposition. In children of an irritable 
habit of body, and disordered bowels, the breathing 
becomes sometimes much oppressed and anxious, 
although no pectoral inflammation exist. (Armstrong.) 
The oppressed respiration, here, depends on irritation, 
and must not be confounded with the oppressed re- 
spiration from pulmonic inflammation; — for, in the 
former, bleeding would injure, in the latter, it would 
be indispensable. 

Diagnosis. Dyspnoea from irritation is variable, inter- 
mitting, being sometimes very great, at others quite 
easy. Is increased on assuming the erect position; 
the respiratory motions of the chest being very percep- 
tible. When produced by inflammation, the oppress- 
ed breathing is permanent — is relieved by the erect 
position, the muscles of the abdomen being strongly 
moved in the acts of respiration. (Armstrong.) Bron- 
chitis is distinguished by the difficulty of respiration 
being attended with a pale and anxious countenance, 
livid lips, unequal distribution of animal temperature, 
and rattling noise in the chest. 

Treatment. Very little remedial treatment required 
in mild and regular cases. Gentle aperients, and tepid 
diluent drinks, are in general sufficient. When the 
eruptive fever is very moderate, the mildly stimulating 
diaphoretic ptisans are serviceable— such as infusion 
of sage, marjoram, balm, &,c. Bleeding rarely neces- 
sary, in cases unattended by local inflammation. When 
the general febrile excitement is violent, moderate 
bleeding will prove beneficial; and in cases attended 
with pulmonic, or other internal inflammations, bleed- 
ing, both local and general, must be promptly and free- 
ly employed, together with epispastics over the inflam- 
ed part ; the warm bath, impregnated with salt, and 
antimonials. 

In instances where the eruptive fever is imperfectly de- 
veloped, in consequence of great internal venous con- 
gestion — a condition characterized by a feeble pulse, 



128 SCARLATINA. 

pale countenance, and general depression of the vital 
energies — it is necessary to resort to the warm bath, 
stimulating frictions, blisters, moderate depletion, and 
the internal use of warm and gently stimulating drinks. 
A weak solution of carbonate of ammonia, is an excel- 
lent article in such cases. Calomel, in large doses, 
with camphor, pulv. antimonialis, and a few drops of 
laudanum, recommended by Armstrong. 

Profuse diarrhoea and vomiting, about the time the rash 
is appearing, is apt to check the progress of the erup- 
tion, or cause its total disappearance, — the lace be- 
coming pale, the breathing oppressed, the pulse feeble, 
with stupor, or constant disposition to syncope. Here, 
opium, alone or with camphor, is a ^ valuable remedy. 

Emetics particularly useful, when bronchitis occurs, or 
when the air passages are loaded with phlegm. (Arm- 
strong.) 

The air of the apartment in which the patient lies, should 
be kept at a temperature, ranging from 65° to 70°. 
Great care required during convalescence, to avoid 
exposure to variable, cold, and damp weather. 

SCARLATINA. 

Scarlatina is divided into three varieties, viz. Scarlatina 
Simplex, S. Anginosa, and S. Maligna. 

Symptoms of Scarlatina Simplex. It commences with 
the usual symptoms of the initial stages of febrile dis- 
eases. About forty-eight hours after the commence- 
ment of the fever, a scarlet eruption appears, first on 
the face, then on the neck trunk, and finally over the 
whole body. This eruption consists of innumerable 
little pimples running into each other; it is sometimes 
uniformly diffused, at others it appears in large blotch- 
es; pressure with the finger, causes a momentary dis- 
appearance of the redness. Soreness in the throat, is 
generally felt, soon after the fever is developed. The 
skin, during the eruptive stage, is dry, rough, and hot; 



SCARLATINA. 129 

the face flushed ; tongue white, with a streak of red 
round the edges; entire loss of appetite; bowels costive, 
About the fourth or fifth day, the fever and the erup- 
tion begin to Heeline, and in two days more disappear 
altogether; the cuticle generally desquamates after the 
eruption has disappeared. 

S. Anginosa. Eruptive fever more violent than in the 
preceding variety. Head-ache, nausea, vomiting, pra> 
cordial oppression, and muscular prostration, very con- 
siderable in the commencement. Stiffness and dull 
pain in the muscles of the neck. The eruption ap- 
pears on the second or third day of the fever, at which 
time the fauces exhibit a swollen and inflamed appear- 
ance, attended with painful deglutition. Pulse fre- 
quent, and more feeble than in the simple variety. In- 
tense heat of the surface, and great thirst. Tongue dry, 
and very florid along the edge ; great restlessness and 
prostration. Ulcers on the tonsils, particularly if the 
fever continues beyond the fifth day. White flakes of 
coagulable lymph, adhering to the tonsils, readily mis- 
taken for ulcers. The ulcers generally cast off superfi- 
cial sloughs, as the fever declines, and then heal ; some- 
times they become foul, and discharge a thin and acrid 
fluid, which being swallowed, occasions exhausting 
diarrhoea. Deep and fatal coma sometimes occurs in 
the stage of excitement. Abdominal inflammation 
casionally supervenes. Anasarca, a frequent conse- 
quence of S. Anginosa. 

Scarlatina Maligna, commences like the former varie- 
ties. Eruption, at first pale, assuming afterwards a 
dark or livid red color; very variable in its duration, 
and time of appearance. Heat of the skin variable, and 
seldom great. Pulse, at first, active, soon becoming 
small and feeble. Delirium an early symptom. Eyes 
dull and heavy, and cheeks livid. Greyish ulcers soon 
visible on the tonsils — becoming finally covered with 
dark sloughs. Fauces clogged with viscid phlegm, im- 
peding respiration. A thin acrid fluid discharged from 



130 SCARLATINA. 

the nostrils, in the advanced period of violent cases. 
8. Maligna differs from S. Anginosa, principally in 
the sudden and dangerous collapse which occurs in the 
former. The supervention of the collapse, announced 
by diminution of the heat of the surface, great prostra- 
tion, frequent and feeble pulse, dark brown or black 
tongue; petechia and haemorrhage, occur towards the 
conclusion of fatal cases — seldom before the tenth or 
twelfth day. Dr. Armstrong's division of S. Maligna, 
into three varieties, viz. the inflammatory, the conges- 
tive, and the mixed. 

Treatment. Emetics, of great benefit in the forming 
stage, particularly of the anginose and malignant va- 
rieties. Gentle purgatives, and the warm bath strong- 
ly impregnated with salt, are also decidedly beneficial 
in this stage. During the stage of excitement of the 
mild variety of the disease, purgatives, tepid affusions, 
cooling drinks, ventilation, a light diet, with rest, are in 
general all that is required. The daily employment 
of mild laxatives, and the careful avoidance of expo- 
sure to cold and damp air, is the best mode of prevent- 
ing the dropsical swellings, so apt to occur during 
convalescence. In the stage of excitement of 8. An- 
ginosa, cold affusions are highly useful. Cold affu- 
sions and purgatives most beneficial, when used con- 
comitantly, particularly during the first three days of 
the stage of excitement. (Armstrong.) 

After the third day, the affusions should be tepid, unless 
the general excitement and heat of the skin still remain 
very considerable. The skin must be above the natu- 
ral temperature, and dry, to justify the use of cold af- 
fusions. When visceral inflammation exists, with an 
active pulse, bleeding will be proper, — when, however, 
general debility accompanies the local inflammation, 
our dependence must be placed on the internal exhibi- 
tion of opium with calomel, and the application of 
emollient cataplasms over the inflamed organ. Blis- 
ters useful, in such cases, during the first few days of 



SCARLATINA. 131 

ihe stage of excitement — in the stage of collapse, they 
do harm ; rubifacients maybe employed advantage- 
ously. To cleanse the ulcers in the fauces, and expel 
the viscid matter lodged there, emetics are often decid- 
edly useful ; gargles, acidulated with nitric or sulphur- 
ic acid, are beneficial. Moderate portions of wine, and 
the milder tonics, useful during the stages of collapse, 
and convalescence. 
In the inflammatory variety of S. Maligna blood-letting 
is an important remedy. The benefits of bleeding con- 
fined to the first twenty-four or thirty hours of the stage 
of excitement; the blood should be suffered to flow, 
until a decided impression is made on the system. 
Purgatives particularly serviceable, during the stage 
of excitement, in this variety; and calomel is the best 
article for this purpose. Tepid affusions, to be used 
during the use of purgatives. 

The highly inflammatory form of Scarlatina Maligna, when 
treated by prompt bleeding and purging, in the early period of 
the stage of excitement, seldom sinks into a low collapse; and 
when this stage supervenes, after the employment of proper 
depletion, in the commencement, itis rarely necessary to resort 
to active tonics or stimulants. 

When the disease assumes the congestive character — 
that is, when, instead of manifest febrile excitement, the 
face remains pale, the skin cool, the sensorial functions 
blunted, with great anxiety and prsecordial oppres- 
sion, the warm saline bath, followed by stimu- 
lating frictions, and the application of bottles or blad- 
ders filled with hot water, together with the free use of 
warm diaphoretic ptisans, such as infusions of catnip, 
balm, or eupatorium perfoliatum, and large doses of 
calomel, (fifteen or twenty grains) are the remedies to 
be particularly relied on. Dr. Armstrong advises 
bleeding, which, though a hazardous remedy, may, 
with cautious management, do much good. Calomel 
in large doses, particularly efficacious. Having estab- 
lished a general febrile reaction, by the means just men" 



132 ERYSIPELAS. 

tioned, recourse should be had to the milder stimulat- 
. ing remedies, such as infusion ofserpentaria,wine whey, 
and, as the disease advances, and the signs of prostra- 
tion become more prominent, carbonate of ammonia, 
wine, camphor and opium. Capsicum, an excellent 
medicine inthestage of collapse, both as a gargle, and as 
an internal remedy. 

Two table-spoonfuls of red pepper, and two tea-spoonfuls of cu- 
linary salt, are to be beat into a paste, on which half a pint of 
boiling water is to be poured, and strained off when cold. An 
equal quantity of very sharp vinegar being added to this in- 
fusion, a table-spoonful of the mixture, every hour, is a pro- 
per dose for an adult. Mr. Stephens asserts^ that he gave it 
in four hundred cases, many of which it cured, after they had 
assumed the most alarming state. I have, in a few instances, 
employed this remedy with signal advantage. 

Cinchona, formerly much employed in this disease; it is 
inferior, however, to the carbonate of ammonia and 
opium, capsicum, serpentaria, and camphor. 

ERYSIPELAS*. 

General description. Fever, varying in different cases, 
from the highly inflammatory to the low typhous grades. 
Superficial inflammation sometimes preceded, at oth- 
ers followed by the fever — commencing in an irregu- 
larly circumscribed blotch, and soon extending itself 
over a greater or less extent of surface; no pulsation or 
tension felt in the inflamed part, the pain being of the 
burning and pungent kind; tumefaction often conside- 
rable. Small vesicles, or blisters, containing a limpid 
fluid, appear after the inflammation has continued for 
some time. When resolution is about taking place, 
the inflamed and red surface becomes pale or brown- 
ish-yellow; soon after which the cuticle desquamates 1 . 
No regularity, either in the duration of the inflamma- 
tion, or its time of appearance. 

Erysipelas occurs under several modifications, each ma- 
nifesting prominent peculiarities, both in relation to 
the local and general phenomena, viz. 



ERYSIPELAS. 133 

1. Erysipelas phlegmonodes. Fever, of the syno- 
cha grade; erysipelatous inflammation, generally 
occurring in the face — sometimes on the extremi- 
ties. Color, bright red; swelling, about the se- 
cond day of the fever ; and vesicles about the fourth 
day ; about the sixth day, the swelling and fever 
begin to subside, and desquamation of the cuticle 
takes place by the eighth day. Very rarely ter- 
minates in suppuration. In old people, sometimes 
protracted to the twelfth or fourteenth day. Dif- 
fers principally from the other varieties, in the 
high grade of febrile excitement which attends it, 

2. Erysipelas cedematodes. Color of the inflamed 
skin, pale red or yellowish brown; heat and 
burning pain, inconsiderable ; swelling comes on 
gradually, has a shining surface, and pits, on 
strong pressure. Vesicles are very numerous 
and small — burst , on the second or third day, and 
change to dark colored scabs. When the head is 
affected, the swelling is so great, as to close the 
eyes, and render the whole face exceedingly bloat- 
ed. Vomiting is an early symptom, and delirium 
and coma often supervene, as the disease ad- 
vances. The debilitated, and habitually intem- 
perate, most subject to this variety of the disease. 
Dangerous, when the head is its seat — rarely so, 
when the extremities alone are affected, except 
when it terminates in suppuration. 

3. Erysipelas gangrenosum. Usually occurs in 
the face and neck; attending fever of a typhous 
grade; slow delirium and coma, almost invari- 
ably attend throughout its whole course; inflamed 
skin, of a dark red or livid color ; blisters small 
but not numerous, often terminating in gangre- 
nous ulcers. Suppuration and gangrene of the 
cellular substance very common. Always tedious 
and dangerous. 

4. Erysipelas eraticum. Inflamed blotches appear 



134 ERYSIPELAS. 

ing in succession on various parts of the body — 
the first blotches generally disappearing before the 
last make their appearance. 
5. Erysipelas neonatorum — a variety of the dis- 
ease peculiar to infants soon after birth. It al- 
most always commences about the genitals or um- 
bilicus, and thence spreads over a greater or less 
extent of the body. The affected parts swell con- 
siderably, become hard, are of a dark red color, 
and very painful to pressure. Generally connect- 
ed with green and fetid discharges from the bow- 
els, and colic pains ; it continues from seven to 
fourteen, or even twenty-one days. Apt to termi- 
nate in gangrene and tedious suppurations. 
Suppuration, in erysipelatous inflammation, always com- 
mences in the cellular membrane; the pus formed is 
thin and acrid, and never collected in circumscribed 
cavities. 
Erysipelatous inflammation, sometimes extends to the in- 
ternal viscera — not by metastasis, as some have alleg- 
ed, but by a spreading of the inflammation from the 
external to the internal parts. The organ most com- 
monly thus affected is the brain — an occurrence gene- 
rally fatal. 
There is a variety of erysipelas, attended with prominent 
symptoms of disorder of the biliary system, and fever 
of the synochus grade. This is the erysipelas phleg- 
monodes biliosum, which has been lately so well des- 
cribed by Mr. Copeland Hutchinson. The fever in 
this variety of the disease, resembles the ordinary bi- 
lious remitting fever. The whole surface, in some 
cases, acquires an icteric hue. The pain and irrita- 
tion are great. 
Causes. A natural predisposition to this a disease appears 
to exist in some instances. Habitual intemperance in 
persons of a cachectic disposition, predisposes'to ery- 
sipelas. In persons either naturally or accidentally 
predisposed to the disease, it may be produced by lo- 



ERYSIPELAS. 135 

cal injuries, particularly of the scalp. Violent rage has 
been known to produce it. (Richter.) A peculiar 
constitution of the atmosphere, and hence its occa- 
sional epidemic appearance. Intestinal irritation; 
this I believe to be a very frequent cause of erysipelas ; 
it is unquestionably so in infants. The contaminated 
air of crowded and ill-ventilated apartments; hence 
its frequency in ill- ventilated and crowded hospitals. 
Derangement of the biliary organs. Some observa- 
tions on the inflammation produced by the rhus toxi- 
codendron. 
Treatment. — The general treatment must accord with 
the character of the attending fever. It must be strictly 
antiphlogistic, when the fever is of the synocha grade ; 
though frequent or copious bleeding is rarely neces- 
sary, unless coma or violent delirium exists. Cathar- 
tics are among the most useful general remedies in this 
disease. Purging is especially beneficial when the face 
is affected. The saline cathartics the best in the phleg- 
monoid variety ; calomel to be preferred when symp- 
toms of biliary disorder attend. Two or three alvine 
evacuations should be procured every twenty-four 
hours. Emetics highly beneficial in the beginning of 
the disease — more especially in the bilious modifica- 
tion. Diaphoretics are serviceable. The saline mix- 
ture, with a small portion of tart, antim. a good dia- 
phoretic. I have derived much benefit from small 
doses of ipecac, and calomel in combination. When 
the fever is of a typhoid grade, mercurial laxatives, in 
conjunction with stimulants or tonics, are to be chiefly 
relied on; the carbonate of ammonia, and sulphate of 
quinine , exceedingly valuable in such cases. Opium 
with sulphate of quinine, particularly valuable after 
symptoms of gangrene have made their appearance in 
the gangrenose variety. In the early period,however, 
of this variety, free purging with calomel, will render 
the necessity of stimulants and tonics less urgent in the 
latter stages. 



136 ERYSIPELAS. 

After suppuration has taken place, opium, camphor, and 
quinine, are to be employed in doses corresponding to 
the degree of prostration. 

In every variety of this disease, laxatives are of primary im- 
portance. From considerable experience in the treatment of 
this malady, I am satisfied that alterative doses of calomel, 
with the daily employment of saline purgatives, will do more 
towards the reduction of the disease, than, perhaps, any other 
plan of general treatment that can be adopted. The calomel 
may be advantageously combined with small portions of ipeca- 
cuanha. One grain of the former, and three of the latter may 
be given every four hours. 

Local Treatment. Certain external applications gener- 
ally decidedly beneficial, the assertion of Bateman and 
others to the contrary notwithstanding. Cold applica- 
tions, such as solutions of sugar of lead, cold water, or 
emollients, generally do harm, The applications must 
be of a stimulating cliaracter. A solution of corro- 
sive sublimate in water, in the proportion of four grains 
to an ounce of water, is an excellent application. The 
blue mercurial ointment is also a very good local re- 
medy ; I have frequently employed it with much ad- 
vantage .* I have also used a weak solution of sul- 
phate of copper, with prompt success. A solution of 
lunar caustic, in the proportion of four grains to one 
ounce of water, will sometimes do much good. I have 
used it in two instances with manifest advantage. 

Blisters are often highly useful. They must be laid im- 
mediately over the inflamed surface. Lard, used by 
Brodie with benefit. 



* Both these remedies were first recommended by American physi- 
cians; the former, by Dr. Schott of Philadelphia, and the latter, by Dr. 
Dean of Chambersburg. 



H^EMO RRH AGI.E. 137 



CHAPTER XVI 



HJIMORRHAGIi;. 

Haemorrhages are divided into active and passive. In 
the former there is a preternatural determination of 
blood to the place from which the haemorrhage occurs, 
with an increase of local vascular action, heat, and co- 
lor. In the latter, there is no sanguineous congestion, 
nor increased activity of the capillaries from which the 
blood flows. Bichat contends that, whether of the ac- 
tive or passive kind, spontaneous haemorrhages are al- 
ways mere sanguineous exhalations, and never the 
consequence of rupture of a vessel. This opinion is 
not sustained by general observation. 

Haemorrhages occur much more commonly from the 
mucous membranes, than from the other structures of 
the body. Local congestion, in the part from which 
the blood flows, is almost invariably present. This 
congestion may be the result of an irritation existing 
in the part, or of one seated elsewhere. Excessive loss 
of blood, with the excess of serum — intestinal irrita- 
tion — organic disease — obstruction. 

A natural predisposition to haemorrhage exists in some 
individuals — and this is even hereditary in some in- 
stances. Remarkable instances of this kind are on 
record. The predisposition to the different kinds of 
haemorrhage, varies with the age of individuals. Thus 
the haemorrhages of young people, occur generally 
from parts situated above the diaphragm ; whilst in per- 
sons of advanced age, they are most apt to take place 
from parts situated below this dividing, muscle. Du- 
ring childhood, bleeding from the nose is most com- 
mon; between the age of puberty and thirty years from 



138 EPISTAXIS. 

the lungs; in middle life from the rectum, and in very 
old people, from the kidneys and bowels. 
Prognosis. Passive haemorrhages more dangerous than 
active ones. The cause of this explained. When 
they depend on organic disease, they are more intrac- 
table. The prognosis depends, in a great degree, on 
the organ from which the haemorrhage proceeds; a 
haemorrage from the lungs being cceteris paribus, 
more dangerous than one from the stomach. 

The general indications in the treatment of haemorrhages 
are, 1. To diminish the momentum of the blood in 
the general circulation, when it is preternaturally aug- 
mented ; 2. To lessen the determination of blood to, 
and moderate the local vascular action in, the part 
from which the haemorrhage occurs. The diet should 
be simple and unirritating. 

EPISTAXIS. 

Premonitory symptoms of the active variety. Weight 
and tension in the temples; throbbing pain in the head ; 
strong pulsation of the temporal arteries; ringing in 
the ears; vertigo; flushed countenance; tickling in the 
nose. In weak and irritable subjects, there are, in ad- 
dition to these symptoms, others denoting a nervous 
or spasmodic condition, viz. creeping chills; a copious 
flow of pale urine; disposition to syncope; cold extre- 
mities, &c. The blood seldom flows from both nos- 
trils at the same time. 

Exciting causes. Whatever is capable of causing a pre- 
ternatural determination of blood to the* head, may 
produce this haemorrhage. 

Prognosis. Frequent bleeding from the nose during 
childhood, is often connected with a natural predispo- 
sition to haemoptysis and phthisis in after-life. When 
epistaxis occurs frequently in advanced age, we may 
presume the existence of visceral obstruction, or pre- 
disposition to apoplexy. It may be regarded as salu- 



HJ3MATEMESIS. 139 

tary in the stage of excitement, in all forms of fever; 
in the stage of collapse, it is a fatal sign. Epistaxis 
most dangerous in debilitated and irritable subjects. 
Seldom, though sometimes fatal, from the mere loss of 
blood. 

Treatment. When this haemorrhage occurs in conse- 
quence of the suppression of some habitual sanguineous 
evacuation, it must not be arrested unless it become 
excessive. When it is attended with a strong pulse, 
and with manifest symptoms of cephalic congestion, 
bleeding from the arm, and warm pediluvium, cold ap- 
plications to the head, cooling drinks, the internal use 
of large doses of nitre, laxative enemata, and rest with 
the head in elevated position, are the measures to be 
principally relied on. 

Styptics are improper under the circumstaneesjust men- 
tioned—they are often required, however, in cases at- 
tended with feeble arterial action, from exhaustion or 
habitual debility. The most useful styptics are, alum, 
kino, spirits of turpentine, and sugar of lead. In obsti- 
nate cases, a blister to the back of the neck, will often 
succeed after other applications have failed. The inter- 
nal use of sugar of lead, is an excellent remedy in ev- 
ery variety of spontaneous haemorrhage. Mechanical 
compression, by means of dossils of lint introduced 
into the nostrils, rarely fails to arrest the bleeding. 

H2EMATEMESIS* 

Premonitory symptoms. These are almost always pro- 
minent. The principal are ; weight and pressure in 
the stomach, want of appetite, or voraciousness, acid 
eructations, pain in the hypochondria, nausea, anxiety, 
ringing in the ears, disposition to syncope, small, con- 
tracted, and irritated pulse, alternate flushes of heat and 
chills, palpitation, cold extremities, pale and contracted 
countenance, and finally, increasing anxiety and con- 
striction about the breast, and obtuseness of the senses. 



140 HiEMATEMESlS. 

The quantity of blood thrown up is generally conside- 
rable, and almost always very dark — sometimes in 
clots, occasionally, quite fluid. Relief is felt after the 
blood is thrown up. The darker the blood, the longer 
it must have lain in the stomach, and the slower must 
have been the effusion. A portion of the blood al- 
ways passes into the bowels, and is afterwards evacu- 
ated by stool. 

Causes- Impeded circulation of the blood in the abdo- 
minal viscera, from visceral indurations; hence its fre- 
quency in habitual drunkards. Suppressed menstrua- 
tion ; particularly in females soon after the age of pu- 
berty, Suppressed hsemorrhoidal discharge; habitual 
constipation ; pregnancy ; mechanical injuries or erosion 
of the mucous membrane of the stomach. 

Prognosis. Not attended with great danger, when it 
occurs in conseqnence of suppression of the menses, or 
hsemorrhois; by recurring frequently, however, it leads 
to dropsy, inveterate dyspepsia, hysteria, hypochondri- 
asis, &,c. It is not apt to become habitual. It is more 
dangerous when it arises from visceral indurations^ 

Treatment. Bleeding, when the pulse is tense and 
corded. Revidsices, (i. e.) sinapisms to the epigas- 
trium, or dry cupping ; warm pediluvium, purgative en- 
emata. Internal styptics, viz. sugar of lead, muriated 
tincture of iron; spirits of turpentine; alum-whey; mu- 
riate of soda ; cold water ; decoction of nettles, (urtica 
tlioica.) Of these I have found the spirits of turpen- 
tine the most effectual. From ten to fifteen drops are 
to be used every half hour. Internal remedies are, 
however, rarely particularly beneficial, incases depend- 
ing on organic visceral disease. In chachectic females, 
the muriated tincture of iron is an excellent internal 
remedy for habitual haematemesis. Emetics lately re- 
commended by Dr. Sheridan. Purgatives strongly 
recommended by Hamilton, particularly when the 
disease occurs in females between the ages of eighteen 



HEMATURIA. 141 

and thirty, and is unattended by visceral disorganiza- 
tion. I have used them with advantage. 

HEMATURIA. 

The haemorrhage may proceed from the urethra, the blad- 
der, the ureters, or the kidneys. When from the 
urethra, the blood is unmixed with urine, and flows 
without any evacuant effort. When from the bladder, 
there is dull pain or a sense of uneasiness in the region 
of this viscus, accompanied with painful erections, and 
burning pain in the glans penis — the blood not being 
intimately mixed with the urine, but suspended in small 
flakes or coagula in it. When the blood comes from 
the kidneys, it is very intimately mixed with the urine, 
without flakes or small coagnla, and settling down into 
a uniform mush-like substance at the bottom of the ves- 
sel in which the urine is left standing. 

Old people, particularly those who are affected with hse- 
morrhois, are most subject to this haemorrhage. Cor- 
pulent and plethoric females are apt to void bloody 
urine, about the period when the menses cease to recur. 

Causes. Mechanical irritation from calculi or other 
causes ; acrid substances conveyed to the bladder, eith- 
er through the medium of the circulation, or by injec- 
tion ; organic affections of the urinary passages ; sup- 
pression of menses or hsemorrhois ; gonorrhoea j denti- 
tion. (Richter.) 

Prognosis. Seldom attended with immediate danger. 
When habitual, it is apt, in old people, to terminate in 
dropsy. 

Treatment. Bleeding when the pulse is active, assisted 
with purgative enemata. When occasioned by calcu- 
li, opium, with sugar of lead, and the warm hath, are 
generally beneficial. When acrid or stimulating sub- 
stances conveyed into the bladder through the circula- 
tion, or otherwise, are its cause, the free use of mucila- 
ginous drinks, with opium, will prove most beneficial. 



142 HJSMORRHOIS. 

The muriated tincture of iron, is an excellent inter- 

- nal astringent in cases not immediately the consequence 
of irritation from calculi, or other irritating substances. 
Twelve drops may be given three or four times daily. 
In habitual hematuria, a caustic issue on the inner 
part of the thigh, or near the groin, on the abdomen, 
has been known to do much good. Uva ursi, decoc- 
tion of peach leaves, and other astringents rarely bene- 
ficial. 

iOEMORRHOIS PILES. 

A discharge of blood, without tenesmus, from small vari- 
cose tumours on the verge of or within the anus. When 
these tumours do not discharge blood, they are called 
blind piles, Qwemorrhoides cobcub?) They are called 
external or internal, according as they are situated 
within or without the anus. 

Premonitory symptoms. Before the blood begins to 
flow, the patient usually experiences various affec- 
tions: viz. head-ache, vertigo, stupor, drowsiness, diffi- 
culty of breathing, nausea, colic pains, pain in the 
loins, a sense of fulness and heat, itching and pain 
about the anus, and often slight fever (molimina he- 
morrhoid alia.') 

The blood sometimes flows, only when faeces are evacu- 
ated — sometimes it flows without the discharge of fae- 
ces. The loss of blood is often very great. I have 
known it so great as to prove fata! . It not unfrequent- 
ly induces great debility, terminating in a leucophleg- 
matic condition, or dropsy. A sudden cessation of 
haemorrhoidal flux, is apt to be followed by other and 
more dangerous affections, as apoplexy, palsy, asthma, 
&c. 

Causes. These are sometimes entirely local in their cha- 
racter and operation, viz: pregnancy, parturition, irri- 
tating purgatives and enemata, protracted constipation, 
ascarides, sedentary employments, compression of the 
abdomen, by tight clothing, &c. There exists in some 



HJEMOPTISIS. 143 

individuals a natural predisposition to haemorrhois. 
In such persons, every thing that has a tendency to 
promote congestion in the portal circulation, will rea- 
dily give rise to the disease, particularly between the 
thirtieth and fiftieth years of age. Females, who men- 
surate regularly, are less subject to it than males. It 
rarely occurs in children. 

Treatment, May we safely attempt to remove or sup- 
press this disease? When it depends on local causes, 
and has not yet become habitual, the sooner we re- 
move it the better. In cases, however, that depend on 
constitutional predisposition, and that have not become 
habitual, from long continuance, or frequent repetition 
or where the general health, or some other chronic af- 
fection, has been improved by its supervention, it is ne- 
cessary to proceed with caution in the application of 
remedies. In many instances the hemorrhoidal dis- 
charge obviates other and much more dangerous ma- 
ladies, by removing or diminishing congestion in the 
abdominal viscera — a source of much more disease 
than seems to be commonly supposed. The principal 
indications are: to counteract inflammation, and local 
plethora in the parts ; to obviate the occasional causes 
of the disease, and to moderate the discharge, when 
excessive, by local applications. To answer these in^ 
tentions, mild aperients, rest in a horizontal posture, 
simple and unirritating diet, cooling drinks, cold and 
mildly astringent applications, will in general suffice. 
When the inflammation runs high, general blood -let-, 
ting, with emollient and anodyne applications, are be- 
neficial. 

ILEMOPTISIS. 

Haemoptisis is generally preceded by slight chills, cold 
extremities, constriction in the breast, palpitation, alter-- 
nate flushing and chillness,an irritated, contracted, and 
feeble pulse, dryness of the fauces, a salty or sweetish 



144 H^EMOPTISIS. 

taste, a sensation of warmth rising in the breast, atten- 
ded with a saltish taste, slight cough, and finally, hae- 
morrhage. Sometimes, however, it comes on suddenly. 
The quantify of blood brought up, is generally small, 
and mixed with the natural mucus of the bronchia; 
occasionally the bleeding is rapid and copious. 

Predisposition. Some individuals have a natural pre- 
disposition to this variety of haemorrhage. Such per- 
sons have narrow and depressed breasts, high shoul- 
ders, long and slender necks, fair hair, blue eyes, de- 
licate and fair skin, sound and very white teeth, red 
cheeks, a clear but feeble voice — they are irritable and 
passionate, and subject to glandular swellings about 
the neck, and catarrhal affections, which pass off slow- 
ly. They are most liable to this haemorrhage, between 
the ages of fifteen and twenty-five. 

Exciting Causes. Atmospheric vicissitudes; violent bo- 
dily exertions ; the abuse of spirituous liquors ; suppres- 
sion of habitual discharges; repulsion of chronic cuta- 
neous eruptions; drying up old ulcers or issues ; metas- 
tasis of gout; mechanical irritation of the respiratory 
passages, by particles of matter floating in the air, or 
gaseous substances; intestinal irritation; organic dis- 
eases of the heart, pregnancy, &c. 

Prognosis. Rarely fatal merely from less of blood — ge- 
nerally the first decided step towards consumption, 
particularly in such as are naturally predisposed to it. 
When no predisposition to phthisis is present, haemo- 
ptisis will frequently pass off, without terminating in 
the former malady. 

Treatmant. Blood-letting is indispensable, when the 
pulse is tense and hard. It is necessary to draw blood 
until the pulse becomes soft. A large sinapism should 
be immediately applied to the breast. Astringents gi- 
ven internally will sometimes put a prompt stop to the 
haemorrhage, particularly after venesection. Sugar of 
lead is the best article of this kind ; when the pulse is 
weak, it may be advantageously combined with opium. 



PHTHISIS PULMONALIS. 145 

From one to two grains of the lead may be given ev- 
ery twenty minutes, until the bleeding is checked. In 
violent cases, six or eight grains should be given at 
once. Large doses of nitras potasste, are an excel- 
lent remedy in pulmonary haemorrhage ; it may be given 
in combination with tart, antimony. Common salt is a 
familiar and useful remedy in haemoptisis. In chronic 
spitting of blood, digitalis, with milk or a farinaceous 
diet, the occasional loss of small portions of blood, blis- 
ters to the breast, and the careful avoidance of every 
thing that can cause inordinate excitement, are the 
principal remediale measures to be depended on. 
Wearing flannel next the skin, and avoiding the influ- 
ence of sudden changes of weather, are circumstances 
of much importance, in the chronic form of the disease. 
Nothing, perhaps, is equal to a uniformly warm climate. 

PHTHISIS PULMONALIS. 

Consumptive symptoms may arise from various and dis- 
tinct pathological conditions. They may depend on 
1. Chronic bronchitis; % Ulceration of the larynx or 
trachea; 3. Chronic pleuritis; 4. Inflammation and sup- 
puration of the substance of the lungs: and 5. Tuber- 
culous matter in the pulmonary tissue, constituting ge- 
nuine phthisis pulmonalis. 

The first variety is generally the result of catarrh, and 
usually called catarrhal phthisis. This, of all the va- 
rieties of consumption, is the most sanable, particular- 
ly so long as the inflammation of the mucous mem- 
brane does not extend to the subjacent parts, or has 
not terminated in ulceration. The diagnostic symp- 
toms in the early stage, are : Countenance pale ; lips 
bluish; hands and feet often cold, and the temperature 
of the surface variable; cough deep, and expectoration 
free from the beginning; slight soreness in pharynx; 
much oppression, but little or no pain in the chest; 
cough rarely excited by full inspiration. Cough al- 



146 PHTHISIS PULMONALIS. 

ways severest in the morning, attended with wheezing 
respiration, until the mucus, collected during the night, 
is expectorated. In all these circumstances, it diners 
from tuberculous phthisis. In the advanced stage, it 
cannot be distinguished from the latter, or genuine form 
of the disease. 

Catarrhal consumption often goes on to a fatal termina- 
tion, without any breach of continuity or ulceration 
whatever — the pus expectorated being a mere secre- 
tion from the inflamed bronchial surface. When this 
variety of consumption is connected with prominent 
derangement of the liver and stomach, it forms what 
has been denominated dyspeptic phthisis. In this 
combination, we have, in addition to the ordinary 
symptoms of phthisis, dyspeptic symptoms, — such as, 
furred tongue, foul breath, unnatural stools, capricious 
appetite, distended epigastrium. 

The majority of consumptions, in this and similar cli- 
mates, are of the catarrhal or bronchial kind. 

When ulceration of the larynx or trachea is its cause, 
the disease is called laryngeal or tracheal phthisis. 
This is a rapid and fatal disease, the instances of reco- 
very being exceedingly few. One of the first, most 
constant, and characteristic symptoms, is a change of 
voice — losing at first its clear sound — then becoming 
hoarse or indistinct, and finally scarcely audible. — 
When the larynx is principally affected, we have the 
following characteristic phenomena: pain in the larynx, 
increased by coughing and pressure; cough most vio- 
lent in the morning, on rising out of bed ; suddenly and 
violently excited, by inhaling cold air and irritating va- 
pors, by swallowing food, and by the use of irritating 
gargles and acid drinks. When the trachea alone is 
affected, the pain is always increased by bending the 
head backwards, or turning it round, and is generally 
felt about its bifurcation. The cough is not excited by 
gargles, or the inhalation of cold air and vapours, but 
readily by active bodily exercise, and by swallowing — 



PHTHISIS PULMONALIS. 14? 

the cough not coming on until the food has descended 
as low down as the sternum, when it is often brought 
up again. Inspiration, during coughing, is generally 
stridulous, as in croup. The fits of coughing are fre- 
quently preceded by sneezing. In coughing, the patient 
puts his hand to the throat, near the breast. The ex- 
pectoration generally consists of small portions of yel- 
low pus, suspended or mixed with a large portion of 
bronchial mucus. The most frequent causes of this 
variety of phthisis are catarrh, whooping-cough, croup, 
and syphilis. 

Chronic pleuritis, gives rise to the third variety of 
phthisis. It is the result of effusion into the cavity of 
the chest — a termination which always takes place, 
sooner or later, in chronic inflammation of the pleura. - 
As the effusion increases, the lung on the side on which 
it occurs, becomes more and more compressed, until it 
is reduced to so small a bulk, as to seem almost com- 
pletely destroyed. Sometimes ulceration takes place 
in the pulmonary pleura, in which case, the effused pur- 
ulent, or sero-purulent fluid, is discharged by cough- 
ing. When this occurs, hectic, with its usual train of 
symptoms, ensue. This variety of phthisis is charac- 
terized by: increased oppression in the breast, on lying 
down ; anhelaiion, by ascending stairs , or other bodily 
exercise; alleviation, in a sitting posture; generally, 
some soreness of the integuments of the affected side; 
pain in the side, confined to a certain space ; difficulty 
of breathing, progressively increased; and, finally, th^ 
absence of pus in the expectoration, and irregularity in 
the hectic symptoms. 

This variety of phthisis is of a very fatal character ; though 
instances of recovery do sometimes occur, by; 1. A 
gradual absorption of the effused fluid, the lungs form- 
ing adhesions with the costal pleura; 2. The escape 
of the fluid, by the formation of a fistulous passage 
from the cavity of the chest into the bronchial tubes; 
3. By the formation of an opening through the inter- 
costal spaces, and the escape of the fluid externally. 



14S PHTHISIS PTLMONALIS. 

Iiifl rmmafion, terminating in pulmonary abscess, con- 
stitutes the fourth variety. This variety is of very rare 
occurrence. 

Tubercular phthisis. This variety occurs only in per- 
sons of a strumous or scrofulous diathesis. Tubercles 
never formed, withouta naturalpredispositionto them. 
They are scarcely organized, being probably formed 
by exudations into the cellular tissue of the lungs. 
They do not always lead to consumption — remaining 
dormant sometimes, without materially affecting the 
general health. Their formation sometimes very rap- 
• id; in which case the usual phenomena of inflamma- 
tion generally attend. Tubercles are never absorbed; 
hence the utter incurableness of perfectly formed tuber- 
culous phthisis. The conversion of tuberculous sub- 
stance into a fluid, not the result ofsuppuration,butof a 
peculiar process of softening. (Laennec.) The sur- 
face of the cavities of softened tubercles, is lined with a 
white, opaque, and soft membrane. Pus is afterwards 
secreted by this membrane. (Bayle.) Under this 
membrane, another one is formed, as the disease ad- 
vances, of a white, semi-cartilaginous appearance, which 
eventually forms a complete lining to the ulcerous exca- 
vations, and gives them a fistulous character. This 
latter membrane exists sometimes before the softening 
has taken place — constituting the encysted tubercle of 
Bayle. There is often more or less chronic bronchi- 
tis, co-existing with pulmonary tubercles; and hence 
puriform expectoration may occur, before these tu- 
mours have undergone the softening process. (Pearson.) 
There are two, and sometimes three, morbid processes, 
in every case of tubercular phthisis; 1. Tubercular ac- 
tion; 2. Chronic bronchitis; 3. Inflammation of the 
pulmonic tissue, generally chronic. 

Although art cannot cure tubercular phthisis, in a state 
of full development, spontaneous cures have been 
known to take place, after the tuberculous matter has 
been evacuated . ( Laennec.) This occu rs in two ways : 



PHTHISIS PULMONALIS 149 

1. By the cavity becoming lined by a semi-cartilagi- 
nous substance, forming " a kind of internal cicatrix, 
analagous to a fistula :" 2. By the cavity being obliter- 
ated by cellular, fibrous, or cartilaginous substance. 

Exciting Causes. All fixed irritations in the abdominal 
viscera; repelled cutaneous eruptions; suppression of 
habitual evacuations; atmospheric vicissitudes; intem- 
perance in spirituous drinks; sedentary employments; 
the incautious use of mercury; haemorrhages; depress- 
ing passions ; the inhalation of irritating substances; ra- 
pid growth, syphilis; onanism. Of all these causes, 
suppression of the cutaneous exhalation by cold, is 
the most common and powerful, in calling into ac- 
tion this fatal malady in those who are predisposed 
to it. 

Characteristic symptoms of the commencement and 
course of phthisis. Tension and slight aching in the 
breast; slight, short and dry cough; slightly oppressed 
perspiration — a sense of tightness being felt in some 
particular part of the chest, on inspiration. At length 
moderate febrile symptoms in the evening; the pulse 
and respiration being preternaturally frequent; cough- 
ing in the morning, great susceptibility of taking cold; 
torpor of the bowels; frequently a benumbing and 
drowsy feeling; tongue moist, covered with a thin white 
fur. As the disease advances, the cough becomes 
more and more troublesome; there is great sensibility 
to low temperature; pearly whiteness of the eyes; skin 
often hot; lips, tongue, and fauces often dry; slight 
chills in the evening, followed by febrile exacerbations, 
with a burning heat in the palms of the hands and 
soles of the feet; expectoration at first scanty and frothy, 
finally thick, puruloid, and often streaked with blood, 
becoming more purulent as the disease goes on; the 
pain in the chest, and evening fevers, becoming strong- 
er and stronger; the patient lies easy only on one side- 
profuse sweats occur during the night; the burning in 
the palms of the hands and soles of the feet is distress- 






150 PHTHISIS PTLMONALIS. 

ing; the pulse very frequent, tense, and quick; and 
small during the febrile exacerbations, but slower and 
languid in the morning, The cheeks have a circum- 
scribed flush, during the febrile excitement. Besides 
the evening exacerbation, there is, in most instances, 
but a slight one about twelve o'clock in the day. To- 
wards the conclusion, colliquative diarrhoea comes on, 
the voice becomes hoarse, the fauces aphthous, the feet 
oedematous; there is sometimes slight delirium; more 
commonly, however, the mental faculties remain entire 
to the last moment. 

Tests for pus. Muriate of ammonia coagulates pus — 
but not mucus. Pus does not coagulate by heat — mu- 
cus does. Water added to the solutions of pus in sul- 

* phuric acid, and a solution of pure potash separately, 
produces in each a copiate precipitate. 

Dr. Young's test. — A small portion of pus, put between 
two glasses, will, when held near the eye, and looked 
through at a distant candle, exhibit an iridescent spec- 
trum, of which the candle is the centre ; — mucus does 
not exhibit this phenomenon. 

Treatment. One of the most important remedial mea- 
sures, in every variety of the disease, is, to restore and 
maintain the regular action of the cutaneous exha- 
lents. This is to be done by wearing flannel next the 
skin, by minute doses of tartarized antimony, and by 
avoiding atmospheric vicissitudes. We must also en- 
deavor to remove every source of irritation, and to 
prevent as much as possible, an. inflammatory con- 
dition of the system — particularly in the incipient 
stage. With this view, a strictly antiphlogistic regi- 
men is to be enjoined, together with occasional small 
bleedings, where the pulse demands it, the use of digi- 
talis, and mild aperients, with gentle exercise on horse- 
back or in a carriage. Another important measure, is 
to divert as much as practicable, the undue determina- 
tion of blood to the pulmonary system, by means of 



PHTHISIS PULMONALIS. 151 

blisters, cupping, and especially by tartar emetic 
ointment applied to the breast. 

Although we cannot expect to cure tubercular phthisis by these 
or any other remedial measures, when once fully developed, 
yet by a strict adherence to them in the incipient stage, we 
may often suspend the disease permanently, or retard itg pro- 
gress in the more advanced periods. Catarrhal consumption 
is not so irresistible in its course, and will not unfrequently 
yield to remedial treatment, even when considerably advanced. 

The use of mercury discussed — generally injurious in 
tubercular phthisis, In consumption from chronic 
bronchitis, balsam copaiva is an excellent remedy. 
"It appears to have a specific influence over the mu- 
cous membrane of the trachea and its branches." 
(Armstrong.) I have myself employed it with decided 
advantage in this variety of phthisis. The inhalation 
of the fumes of tar, has of late years'been much extol- 
led in the cure of consumption. Its power has been 
overrated. In tubercular phthisis it generally does 
harm; in chronic bronchitis it may, and no doubt has 
often done good — but even in this variety of the disease, 
it generally proves injurious, when the habit of the body 
is irritable, and the inflammation active. Dr. Hastings 
speaks very favorably of a combination of extract of 
stramonium, and pulv. ipecac, compos., in the pro- 
portion of one-fourth of a grain of the former, with two 
grains of the latter, taken three times daily. Cincho- 
na is valuable in the advanced stage of catarrhal con- 
sumption, (Broussais, Hastings.) A change of cli- 
mate will sometimes remove the disease, when reme- 
dial treatment is inadequate. 

Tracheal phthisis almost invariably terminates fatally. 
Mercury is said to have been beneficial, particularly 
in cases dependent on a syphilitic taint. An equable 
and mild temperature is one of the most important cu- 
rative means in this, as in the other varieties of phthisis. 
Blisters should be applied to the throat, and kept dis- 
charging. Armstrong asserts, that bats, copaiv. is as 



153 PHTHISIS PULMONAilS. 

beneficial in this, as in the catarrhal variety, when em- 
ployed previous to the occurrence of ulceration. When 
ulceration exists, large doses of cicuta, with minute 
portions of murias hydrarg. are said to be serviceable. 

Phthisis depending on chronic plcuritis, is more amen- 
able to remedial treatment. Here, our chief reliance 
is to be placed on external vesicating or irritating ap- 
plications to the chest . Tartar emetic ointment is the 
best. Active diuretics are beneficial. Squill, in com- 
bination with calomel, is a good article for this purpose. 
Digitalis and squill, useful when effusion has taken 
place. 

Prussic acid, is much extolled by some in phthisis. It 
is, however, a dangerous remedy, and must be em- 
ployed with the utmost caution ; one sixteenth of a drop 
is sufficient for a dose. Sugar of lead an excellent 
remedy to check the colliquative night sweats. Phe- 
landrum aquaticum, much recommended by the Ger- 
man physicians in catarrhal (phthisis pituitosa) con- 
sumption. It is given in doses of from sixteen to 
twenty grains, three times daily. I have known it do 
much good in the advanced stage of the disease. Am- 
pelopsis hcderO) appears to be a useful remedy in this 
variety of the disease.* (Atkins.) The bark of the 
wild cherry tree (prunus virginiana) is a valuable 
tonic in consumption/] - Opium the best euthanasial 
remedy. 



* Phil. Med. and Surg. Jour. Oct. 1826. 
t Vide Eberle's Mat. Med. Article Prun. Virgin. 



APOPLEXY. 



153 



CHAPTER XVII 



NEUROSES. 



APOPLEXY. 



Character. Abolition or suspension of the animal func- 
tions, — the organic functions being uninterrupted ; with 
laborious, generally sterterous, breathing. 

Description. Generally preceded by premonitory symp- 
toms — such "as, vertigo, drowsiness, dull pain in the 
head, irregular and involuntary contractions of the 
muscles of the face, turgidity of the vessels of the head, 
bleeding from the nose, ringing in the ears, loss of me- 
mory or speech, dimness of sight, indistinct articulation. 
Sometimes the attack is sudden, without premonitory 
symptoms. Sterterous breathing, not invariably pre- 
sent in the attack, as is generally alleged. The pulse, 
during the apoplectic state, is at first full, slow, regular, 
and often hard; towards the conclusion of fatal cases, it 
becomes frequent, irregular, and weak. The face is 
livid and full ; the eyes prominent, and often blood-shot ; 
the pupils much dilated, or permanently contracted. 
The attack may last from a few hours to several days. 
Apoplexy seldom if ener destroys life suddenly, as 
is the case with affections of the heart. Most apt to 
occur between the ages of forty and sixty. Persons 
who have short thick necks, and are of a full and ple- 
thoric habit, and indulge freely in eating, drinking, and 
sleep, are most liable to this disease. Great heat and 
cold predispose to it. 
Exciting causes. Whatever tends to determine the cir- 
culation inordinately to the head, may produce apo- 
plexy. The most common of these causes are, over- 
v 



154 APOPLEXY. 

distention of the stomach with r food; the use ofindi- 
gestihle and Stimulating diet; the intemperate use of 
spirituous liquors; viohnt straining in lifting, or in 
evacuating fbeces: violent anger; the direct rays of a 
vertical sun; extreme cold weather; the cold stage of 
intermittents ; stooping, or other positions in which the 
head is in a depending state; impeding the return of 
blood from the head, by wearing cravats too tight, and 
turning the head to look back. Apoplexy is also pro- 
duced by the suppression of habitual discharges; by 
the healing of old ulcers; by metastasis of gout. Irri- 
tation in the stomach and bowels is a frequent cause of 
this disease. 

Proximate Cause. Interruptions of the functions of the 
brain, and consequent deficiency of nervous influence 
in the parts furnished with cerebral nerves. Does this 
interruption of the cerebral functions depend on com- 
pression of the brain, or on mere deficiency of arterial 
blood circulating in this organ, as has been lately main- 
tained? I believe that both conditions (i. e.) compres- 
sion of the brain, and deficiency of arterial blood in it, 
are necessary to the production of genuine apoplexy. 
Cerebral compression may be the result of mere vascu- 
lar turgescence, or of extravasation of blood upon, or 
into, the substance of the brain; or, finally, of serous ef- 
fusion into its cavities, &,c. Blood is very rarely ex- 
travasated upon the surface of the brain, or into its 
ventricles, but almost always into its substance. 
(Bricheteau, Rochaux.) 

Diagnosis. Distinguishable from syncope and asphyxia, 
by the pulse and respiration. The pulse is full, strong, 
and slow, in apoplexy; in syncope and asphyxia, it is 
small and feeble, and sometimes wholly suspended. 
Respiration in apoplexy is slow, laborious, and sterto- 
rous ; in asphyxia and syncope, it is feeble and almost 
imperceptible. Apoplexy, not easily distinguished from 
intoxication; the smell of the breath, habits of the pa- 
tient, &c. will inform us on this point. 



APOPLEXY. 155 

Prognosis. Generally unfavorable, When the result 
of mere sanguineous congestion in the brain, it is in 
general readily relieved. When effusion of serum, or ex- 
travasation of blood has occurred, it is rarely cured. 
Extravasation of blood into the brain, is not necessarily 
fatal, as was formerly thought. 

The observations of Brichteau, Seres, Rochaux, and Riobe, 
prove, that when blood is extravasated into the substance of 
the brain, a cyst is formed around the coagulum, and that this 
coagulum is afterwards absorbed by the vessels of this cyst. 
The cyst finally becomes absorbed itself, and leaves a yel- 
lowish cicatrix or laminated tissue, which is sometimes found 
to contain a small portion of serum. 

Apoplexy may be divided into two varieties ; viz. simple 
apoplexy, which is not accompanied by paralysis; 
complicated apoplexy, which is attended by loss of 
motion, on one or the other side of the body. Mr. 
Seres, of Paris, has ascertained that simple apoplexy 
depends on serous effusion into the ventricles or cir- 
cumvolutions of the cerebrum, without any organic le- 
sion of the cerebral substance. In complicated apo- 
plexy, the substance of the brain is altered ; excava- 
tions are found in it, filled with blood of various ap- 
pearances, according to the time which may have 
elapsed between the extravasation and death — the por- 
tions of brain immediately surrounding these clots, be- 
ing red, indurated, or yellow. Mr. Seres concludes, 
from his observations on this subject, that: — 

1. When- no symptoms of paralysis attend, we may 
presume that the seat of the di.sease is in the me- 
ninges, and that the substance of the brain is not 
altered. This variety, he accordingly calls me- 
ningeal apoplexy. 

2. When the disease is complicated with paralysis, 
the cerebrum is the part principally or wholly af- 
fected ; and this variety he calls cerebral apoplexy. 



156 APOPLEXY. 

It appears, from the observations that have been 
made in the Parisian hospitals, that meningeal 
apoplexy occurs most commonly in the fifteenth, 
and after the sixtieth year of age. 

Cerebral apoplexy generally makes its attack suddenly. 
Meningeal apoplexy usually comes on gradually. In 
this variety, the mouth is never drawn to one side, and 
the patient lies in a straight position . Paralysis almost 
invariably occurs on the side opposite to the one in 
which the cerebral lesion exists. This was observed 
in 171 subjects who had died of cerebral apoplexy, 
accompanied with hemiplegia. When the paralysis is 
universal, the extravasation and cerebral lesion occur 
in the substance of the tuhar anulare, or along the 
base of the skull. Death, from apoplexy, explained. 

Tteatment. The chief indications in the treatment of 
apoplexy, are: to lessen the determination of blood to 
the brain, and to moderate the momentum of the ge- 
neral circulation. This is effected by general and lo- 
cal bleeding, active purgatives, revulsive applications, 
abstemiousness in diet, and stimulating drinks, &c. 
During the apoplectic attack prompt and copious 
bleeding, stimulating purgative enemata, cold applica- 
tions to the head, sinapisms to the feet, cups applied to 
the temples and the back of the neck, and an elevated 
position of the head, are the remedial measures to be 
relied on. When apoplexy comes on, soon after a 
full meal, an emetic should be administered ; blood 
should, however, be previously drawn. Under other 
circumstances, emetics are improper, as they have a 
decided tendency to produce cephalic congestion. On 
this subject, there has been much controversy. I have 
found castor oil, and spir. turpentine, in combination, 
an excellent purgative — it having rarely failed in my 
hands to excite copious purging, which, though of 
much importance, it is often exceedingly difficult to 
procure. 



PARALYSIS. 157 



PARALYSIS. 



Character. Diminution or entire loss of voluntary mo- 
tion, or of sensation, or of both, in some particular part 
of the body, without coma. 

Description. Often the consequence of apoplexy; but 
frequently also, independent of it. Most commonly, 
there is only loss of voluntary motion — sensibility re- 
maining entire, or even morbidly increased. Total 
abolition of sensibility, very rare. The palsied limbs 
generally become soft, wasted, and shrunk — often with 
a peculiar sensation in them, as if insects were creeping 
over them {formication.) Mental hebetude, frequent- 
ly in palsy — especially weakness, and sometimes total 
abolition of the memory. Entire change of the natu- 
ral disposition, occasionally occurs in this disease. 

Paralysis is divided, by nosologists, into three varieties, 
viz: hemiplegia, paraplegia, and local palsy. 

The question, why the power of motion is sometimes lost, 
while that of sensation remains, and nice versa, has given rise 
to much controversy among physiologists. Galen supposed that 
there were two sets of nerves — one destined to sensation, the 
other to motion . What this sagacious physician alleged, on 
mere speculative grounds, has recently been actually demon- - 
strated by Magendie, and Charles Bell. It appears, from the 
experiments of these and other physiologists, that each nerve 
is composed of two distinct parts — the one for motion, and the 
other for sensation. From this anatomical fact, we perceive 
in what manner the phenomenon in question may occur. 

HEMIPLEGIA. 

Paralysis, confined to one side, including the whole half 
of the body, generally the consequence of apoplexy; 
the apoplectic symptoms are sometimes so slight, as to 
escape notice. Injuries done to the head may produce it. 

Cerebral compression, or structural lesion, the proxi-. 
mate cause of hemiplegia. Seres denies that compres^ 
sion is ever the cause, either of apoplexy or hemiple- 



158 HEMITLEGIA. 

gia; his experiments, however, are not conclusive ; they 
are contradicted by those of Portal, and of Mr. Astley 
Cooper. 
Hemiplegia often comes on gradually, with the usual 
symptoms of approaching apoplexy; occasionally, its 
attack is sudden. Anomalous symptoms. This af- 
fection sometimes terminates in a few days — more ge- 
nerally several months; and occasionally it remains 
permanently. Sometimes a greater or less degree of 
amendment occurs, and then the disease remains sta- 
tionary. 

PARAPLEGIA. 

paralysis of the whole lower half of the body, the parts 
above the hips remaining unaffected, Occurs most 
commonly after the middle period of life; and accord- 
ing to Baillie, more frequently in men than women. 

Causes. Most commonly seated in the brain, (Baillie, 
Earle, flalford, Copeland;) sometimes in the spinal 
marrow, producing an interruption to the passage of 
the nervous influence along the spinal cord, to the 
nerves of the lower extremities. The most common of 
those causes, which act immediately on the spinal 
marrow, are: thickening of the theca vertebralis ; serous 
effusions into it, exostosis on the internal surface of the 
vertebree. The higher these causes exist in the medulla 
spinalis, the higher will the paralysis extend. When 
above the fifth cervical vertebra, the hands will be pa- 
ralysed ; if below the eighth, they will not be affected. 
The effusion may occur, first between the membranes 
of the brain, and afterwards sink down in the theca 
vertebralis, and press upon the lower portion of the 
spinal cord. 

When the brain is the primary seat of the disease, pain 
in the head, giddiness, drowsiness, impaired vision, and 
defective memory, usually precede the paralytic at- 
tack. The paraplegiac affection always comes on 



PARAPLEGIA. 159 

gradually — first by stiffness and slight difficulty of di- 
recting the motions of the lower limbs; by degrees, 
the assistance of a stick is required to balance the body; 
the urine is voided with difficulty, and finally passes 
off involuntarily — the paralysis becomes more and 
more complete, the faeces passing off unrestrained by 
the will. 

PARALYSIS PARTIALIS LOCAL PALSY. 

Local paralysis consists of want of motion, or of sensa- 
tion, or of both, in some particular part or organ of the 
body. It may attack some viscus, or the organs of 
f^sense, destroying or blunting their respective functions. 
It occurs in one extremity; in the muscles of degluti- 
tion; in those of the organs of speech, and even in 
a single muscle. It most frequently, however, occurs 
in the muscles of the face. Persons affected with fa- 
cial paralysis, are deprived of the power of closing or 
opening the eyelids — of contracting the brow — of ele- 
vating the nose or lip — of shutting the mouth — of re- 
taining the saliva — of raising the corner of the mouth — 
of whistling or blowing, &c. The wing of the nose, 
on the palsied side, is collapsed; the mouth drawn 
towards the opposite side; the teeth exposed. The 
power of masticating remains — the tongue too retains 
its powers. 

Causes. Facial paralysis is [produced by some injury 
sustained by the portio dura, either in consequence of 
surgical operations, abscesses, bruises, or other injuries 
in the parotid region. It occurs also in consequence 
of thickening of the sheath of this nerve ; of necrosis at 
the canal of the] temporal bone, through which it 
passes out; and frequently from sudden exposure to 
cold, producing inflammation of the nerve. It has been 
produced by a blow on the head; by the suppression 
of cutaneous eruptions; and by tumours pressing on 
this nerve. 



160 PARAPLEGIA 

Paralysis of the wrists is produced by the poisonous influ- 
ence of lead; by bilious colic; and sometimes by dy- 
sentery. Whatever interrupts the free nervous com- 
munication between a part and the common sensorium, 
may produce paralysis in such part. 

Treatment. Blood-letting of primary importance in 
the commencement of hemiplegia, preceded by apo- 
plectic symptoms, and attended with a full and strong, 
or small and tense pulse. In some instances the pulse 
is small and feeble, in which case, bleeding is of course 
to be avoided, or at most used with particular circum- 
spection. Purgatives, perhaps, still more beneficial 
than blood-letting. In debilitated, leucophlegmatic, or 
hydropic subjects, mustard or capsicum may be very 
advantageously given in union with cathartics. An 
ordinary dose of calomel and jalap, with from 20 to 30 
grains of mustard, or from six to eight grains of capsi- 
cum, forms an excellent purgative under such circum- 
stances. Emetics have been particularly recommend- 
ed in hemiplegia. They must be given in large doses, 
on account of the unirritable state of the stomach in 
this complaint. They are useful when the attack of 
the disease occurs' soon after a full meal, or during the 
existence of dyspepsia In recent cases, with signs of 
cephalic congestion, they are hazardous, unless blood 
be previously drawn. Stimulating enemata are useful 
remedies. Much advantage may be derived from ru- 
bifacient, vesicating, and stimulating applications to the 
paralytic parts. The depletory remedies just mention- 
ed, cease to be proper after the disease has assumed a 
chronic character — that is, after the apoplectic sym- 
toms have disappeared, and the undue determination 
to the head no longer exists. Means of an opposite 
character are now to be used, i. e. external and inter- 
nal stimulating remedies. • The former are sinapisms, 
warm bathing, blisters, moxa, cupping, galvanism, 
electricity, and frictions with the flesh brush, dry flan- 
nel, or with stimulating fluids. Blisters and sinapisms 



PARAPLEGIA. i61 

must be employed with caution, when the paralysis is 
complete, lest sloughing or mortification ensue. They 
should be employed only as rubifacients in such cases, 
In general, mere dry frictions, with flannel or the flesh 
brush, will do more good than where rubifacients are 
used. Electricity has been employed with success 
in this city. It must never be employed in strong 
shocks ; weak sparks are more efficacious, and less 
apt to injure. Galvanism is more efficacious than 
electricity ; it must be applied with only a moderate 
force. Moxa has been used with success in general 
paralysis, applied along each side of the spine, near 
the first dorsal vertebra, by Dupuytren. 
Among the internal remedies, the following are the 
most useful: — Rhus toxicodendron. I have succeed* 
ed in curing two cases of hemiplegia, by the saturated 
tincture of the leaves of the rhus. The dose is from 
twenty to sixty drops, three times daily. Professor 
Ossan of Berlin, recommends it to be given according 
to the following formula: — B. Tinct. rhois, toxicoden. 
gss. Tinct. aconit. neamont. Tinct. guaiaci. aa 31J- m, 
Dose, forty drops every three hours. The nux vomi* 
ca has of late years been much employed, and not un-? 
frequently with success, in paralysis. When used in 
adequate doses, it produces strong convulsive contract 
lions, more particularly in the paralytic parts. The 
extract is usually employed. It may be commenced 
with in the dose of two grains, twice a day, and F gra-? 
dually increased until the spasmodic contractions come 
on. The arnica montana, is a favorite remedy with 
the German physicians in paralytic affections. Mus-> 
tard seed, internally, has been found useful ; I have em- 
ployed it with advantage in hemiplegia. Iodine has 
been used with success, in paralysis depending on tu-? 
mours or fluids pressing on the brain or spinal cord. 
Dr. Manson has related some remarkable instances 
of its beneficial operation. In paralysis of the tongue, 
a few drops of the ol. cajeput, put on the organ daily, 
x 



162 EPILEPSY. 

has been found serviceable. Chewing the root of the 
anthemis pyrethrum, has also done good in palsied 
tongue. Would not moxaustion over the mastoid re- 
gions prove beneficial in this variety of palsy ? In pa- 
ralysis from lead, mercury is an excellent remedy ; the 
nitrate of silver has also been used with advantage, 
in this species of paralysis. When the wrists are pal- 
sied, the application of a splint along the inner side of 
the fore-arm has done much good. (Pemberton.) 

EPILEPSY. 

Character. Convulsions returning at uncertain inter- 
vals — accompanied with loss of sense and voluntary 
motion, and terminating in deep sleep. 

Premonitory symptoms. A confused and wandering 
state of the mind ; vertigo ; ringing in the ears ; indis- 
tinct vision; pain in the head; pain and anxiety in the 
precordial region ; change of the natural disposition ; 
spasmodic twitches of the muscles of the face ; aura 
epileptica, and a feeling of terror and alarm are the 
most common. 

Symptoms of the paroxysm. The attacks frequently 
occur at night, while the patient is asleep. If he is 
sitting or standing, he suddenly falls down, and be- 
comes more or less violently convulsed. The counte- 
nance is frightfully distorted, and generally of a livid, 
and sometimes almost black hue — occasionally it is 
pale; the veins of the head and neck are turgid; the 
heart palpitates violently, and the breathing is oppress- 
ed and laborious, and in violent cases sterterous. A 
copious flow of frothy saliva occurs towards ilie 
termination of the paroxysm. As the convulsions 
abate, stupor or deep sleep comes on, out of which the 
patient awakes in a state of mental torpor or confusion, 
which often continues for many hours — the counte- 
nance exhibiting a fatuous and stupid cast. The dura- 
tion of the paroxysm varies in different cases, from a 



fcPILEfrSY* 163 

few minutes to Several hours. Sometimes there is but 
one fit at a time ; at others* three or four, and even more 
paroxysms, occur in quick succession, before the dis- 
ease terminates. The fits are in general more pro- 
tracted in children than in adults. Sometimes the at- 
tacks are strictly periodical in their recurrence, more ? 
generally, however, they return at irregular intervals 
and the duration of these intervals is exceedingly vari- 
ous. Epilepsies, depending on intestinal irritation and 
catamenial irregularities, are njost apt to become pe- 
riodical. (Richter.) The periodicity of this disease is 
ascribed to lunar influence, by Mead, Balfour, and 
others. This opinion is not supported by sufficient tes- 
timony to entitle it to credit 

Epilepsy is seldom fatal, except by the intervention of 
apoplexy. By repeated recurrence, it never fails to im- 
pair the understanding — terminating sometimes in per- 
fect idiotism. 

Autopsic phenomena. According to Wentzel, the cere- 
bellum is much more frequently found diseased than 
the cerebrum. The pineal gland is often found in a 
morbid state; tumours and other structural derange- 
ments are, in some instances, discovered in the cere* 
brum. In the cerebellum, have been noticed indura^- 
tions and a peculiar friable matter between its lobes, 
with destruction of a portion of their substance. In 
many instances, however, not the slightest traces of 
organic disorder are discoverable, either in the cere- 
bellum or cerebrum. 

Predisposing causes. Predisposition sometimes consti- 
tutional, and even hereditary, and always augmented 
by the attacks of the disease. Young people, about 
the age of puberty, most liable to epileptic attacks. 

Exciting causes. Some act directly on the brain — the 
disease being then called idiophatic. Others act on 
remote parts — affecting the brain sympathetically — 
this constitutes symptomatic epilepsy. Among the 
former causes, are: malformation of the skull; depress- 



i64 EPILEPSY. 

ed bones ; exostosis from the internal surface of the 
craiiium; organic derangements; vascular congestions 
and effusions in the brain, &,c. Among the most com- 
mon causes of the latter class, are: intestinal irrita- 
tion from worms and other irritants ; dentition ; suppres- 
sion of the catamenia i of hsemorrhois, and of perspira- 
tion ; the drying up of old ulcers and issues; the reper- 
cussion of exanthematous eruptions, or of chronic cuta- 
neous diseases, as measles, small-pox, itch, and tinea 
capitis. Excessive^anguineous and other evacuations ; 
onanism; various poisons, both vegetable and mineral; 
habitual intemperance in the use of spirituous li- 
quors; pregnancy; irritation from biliary concretions 
and urinary calculi; sudden and violent terror ; anger, 
and grief; disagreeable and strong impressions on the 
senses; spiculae of bones, tumours* &.c. pressing upon, 
and irritating some nerve ; the sight of a person affected 
with the disease. 

Proximate cause. Various opinions expressed by au 
thors. A temporary local turgescence of the cerebra 
vessels, is probably the immediate cause of the epilep^ 
tic paroxysm. (Johnson.) According to Mansford, an 
accumulation of electric matter in the brain, constitutes 
the proximate cause. Others regard organic derange- 
ment of some part of the brain as the immediate cause* 
[ regard the first opinion as the most probable. 

Diagnosis. Sometimes confounded with hysteria. 
They may be distinguished by the following circuun 
stances. In hysteria, there is no foaming at the 
mouth, nor is the countenance so livid and distorted 
as in epilepsy; the hysteric paroxysm does not termi- 
nate in heavy sleep, as does the epileptic. In hyste- 
ria, there are globus hystericus, involuntary laughing, 
weeping, and other hysteric symptoms. 

Prognosis. Not much immediate danger. In relation 
to its sanability, however, the prognosis is always favor- 
able. Symptomatic, more frequently cured than idio- 
pathic epilepsy. Cases depending on catameniai irre* 



EPILEPSY. 165 

gularities, in young females, most frequently yield to 
remedial treatment. The more frequently it has re- 
curred, the more difficult the cure. Epilepsies that 
come on soon after birth, are hardly ever cured. 
Cases produced by falls and blows on the head, are 
very generally incurable. From the period of denti- 
tion, to that of puberty, the most favorable age for the 
cure of this disease* It is more unfavorable, when 
the precursory symptoms consist of some affections in^ 
the head, than when they are felt in other parts, par- 
ticularly the extremeties. Protracted sleep and stu- 
por after the paroxysm, very unfavourable. 

Treatment. In prescribing for epilepsy, we must first 
endeavor to ascertain its original exciting cause— its 
duration — the time and manner of the first attack— 
the constitutional habits of the patient — his age, pur- 
suits, concomitant disorders , temper, and mode of liv- 
ing. It is upon these circumstances alone that a ra- 
tional treatment can be founded. The treatment is 
divided into palliative and curative. The former 
applies to the paroxysms — the latter to the intervals 
between them. The attack may sometimes be pre- 
vented during the period of the premonitory symp- 
toms, by bleeding where there are marks of general 
plethora, brisk cathartics, emetics, a draught of cold 
Water, and ligatures round the limb, above the part to 
which the aura (where this sensation precedes the at- 
tack) has risen. Richter asserts, the emetics are par- 
ticularly useful in warding off an approaching parox- 
ysm, in cases that continue from habit, after the origi- 
nal exciting cause no longer exists. I have known an 
epileptic person, who could prevent the paroxysm, 
when he felt it approaching, by a draught of cold water. 
Jahn mentions similar cases. 

During the paroxysm, our principal objects is to lesson 
the preternatural determination to the head, and with it 
the chance of apoplexy. With this view, bleeding in 
full habits, an elevated position of the head, with cold 
applications to it, the removal of every thing which 



1#6 ECILEPSY. 

may compress the veins of the neck, and sinapisms to 
the feet, may be beneficially employed. No treatment 
will either materially mitigate or shorten the parox- 
ysm. 

The radical cure is to be attempted during the intervals. 
Where the exciting cause can be ascertained, and is of 
a nature capable of being removed, this should be im- 
mediately attempted, as the first and most important 
curative measure. When gastric irritation from worms, 
acidity, and other causes, exists as its cause — as is of- 
ten the case with young children, anthelmintics, 
emetics or purgatives, absorbents and tonics, are pro- 
pen In verminous epilepsy, valerian, in union with 
small doses of calomel and flores zinci, has been found 
efficacious . When suppressed perspiration has given 
rise to the disease, diaphoretics should be employed ; 
here, camphor with tarter emetic, guaiacum, sulphur, 
together with the warm bath, warm clothing, and dry 
frictions, particularly serviceable. When repercussion 
of utaneous affections, or the dying up of old ulcers, 
was the original cause, issues, yesicatories, pustulating 
applications, warm bathing, frictions, and stimulating 
diaphoretics, are the appropriate remedies. When the 
disease arises from menstrual irregularities, means 
must be employed to obviate the morbid determina- 
tion to the uterine system. Here, bleeding is general- 
ly an indispensable remedy; the warm semicupium, 
frictions about the back and loins, stimulating enema- 
ta, the internal use of spirits of turpentine, of tincture 
of cantharides, and other emenagogues, (after proper 
depletion,) are peculiarly serviceable. In epilepsy 
from dentition, blisters behind the ear, leeching, pur- 
ging, scarifying the gums, and fi a mild diet, are especial- 
ly indicated. When onanism is its cause, camphor e- 
ternally, with cold applications to the genitals, and a 
seton in the back of the neck, have been found bene- 
ficial. 

Remedies that are employed empyrically, or that are 



EPILEPSY. 167 

supposed, or do possess specific anti-epileptic powers:— 

Valerian. A very ancient remedy. It should be given 
in as large doses as the stomach will bear — a drachm 
three times daily. It forms a principal ingredient in 
the famous powder of Ragoloi, which according to 
Knopf's analysis, is composed of Valerian, sj. Pow- 
dered orange leaves, ^j. Muriate of Ammonia, grs. ii. 
and ol. cajeput, gtt. iv. Richter has cured inveterate 
cases with this remedy. 

The Misletoe, recommended by De Haen, Van Swieten, 
Hufeland, Stark, Richter. Cullen thinks it may have 
done good, from its having early been an object of su- 
perstition, and thus bringing with it the powerful aid of 
the imagination. Frazer states that he cured nine out 
of eleven cases, with the viscus quercinus, in doses of 
from 9ij. to 31J. twice daily, Dr. Fothergil and Wilan, 
speak well of its powers in this disease. 

Animal Oil of Dipple. According to Richter, particu- 
larly valuable in epilepsies from metastasis of gout, 
rheumatism, and repelled cutaneous eruptions. 

Spirits of Turpentine. Lately much extolled for its 
virtues in this disease. Drs. Latham, Young, Perci-. 
val, Money, and Prichard, have used it with decided 
success. Dose from 3Jss. to 3iij. thrice daily. I have 
lately cured a case with this remedy. 

Paeony root. Agaricus Muscarius. Both much used, 
formerly. 

Artemisia Vulgaris. Has lately^been used with singu^ 
lar success, in the Polyclinic Institution at Berlin ; and 
late numbers of Hufeland's Journal, contain several 
well authenticated cases of its successful employment. 
It is said to be particularly useful epilepsies, coming on 
about the age of puberty, and more so in females than 
in males. The root is given in doses of about thirty 
grains, four times daily, and gradually increased. Et-, 
muller says of it — mire in epilepsia valet. 

Camphor, Musk, Castor, Assafoetida. The first of 
these articles is said to be particularly adapted to cases 



163 



EPILEPSY. 



arising from repelled cutaneous affections, and from 
onanism. 
Stramonium, Belladonna. Both these narcotics have 
been employed with occasional success in epilepsy. 1 
once succeeded in removing the disease in a child, by 
means of belladonna and cuprum ammoniacum. Hufe- 
land speaks highly of the tincture of Stramonium, and 
Odhelius cured eight out of fourteen cases, in the hos- 
pital of Stockholm, with this remedy. 

Opium. Epilepsy has been cured by this narcotic. — * 
Darwin cured two cases with it, and Dr. Huxy relates 
an instance of its successful use. Richter states, that 
cases produced by mental excitement, pain, or exhaus- 
tion, are often benefited by it. 

Phosphorus. This potent article is recommended by 
Horn, Lobenstien-Loebel, and Van Hoven. It is im- 
proper in cases attended with general plethora. 

Zinc. A valuable remedy in this disease. It should 
be given in large doses. Dr. Guthrie commenced 
with eight grains of the flores zinci, and increased the 
dose until it amounted to two scruples a day. Many 
cases are reported of its successful employment. The 
sulphate less useful than the flowers of zinc, in epilepsy. 

Cuprum Ammoniacum. Cullen speaks favorably of its 
powers in this disease. The number of cases report- 
ed of its efficacy, is not inconsiderable. I have used it 
with success in one case. 

Acetate of Lead. Dr. Rush gave this article with suc- 
cess in epilepsy. About fifteen years ago, I reported a 
case which yielded to its powers. This case was 
strictly periodical — the paroxysms returned at each 
full moon. Three grains were given morning, noon, 
and evening, for three or four days previous to the 
usual period of return, and continued for three days 
after this period. It was not till the fifth period of re- 
currence, that the disease was subdued, and the per- 
son has continued free from the complaint to this day, 
although he had suffered its periodical attacks for 



EPILEPSY. 169 

seven or eight years before he come under my treat- 
ment. 
Tin. Strongly recommended by Dr. Shearman, in a' 
late Number of the London Medical Repository. He 
employed the elutriated oxyd of this metal, in doses of 
from 9ij. to 3j. night and morning; and, he assures us, 
with much success. 

Nitrate of Silo er. This article possesses more reputa- 
tion, as a remedy in this disease, than any other article 
of the materia medica. It should be given in as large 
doses as the stomach will hear. We may commence 
with one grain three times daily, and increase it gra- 
dually, which may often be done to a surprising extent. 
Dr. Powel has ascertained, that triple the quantity of 
this article may be taken without inconvenience, in the 
form of pills, as in solution. 

Mercury has been used with success in epilepsy, by Bur- 
serius, Tissot, Houssel, Willis, Etmuller, Frank, Rich- 
ter, Cullen, Locher, and others. It is seldom used at 
the present day. 

Galvanism has been found beneficial in this disease. It 
should be applied steadily and constantly. (See Mr. 
Mansford's work on this subject.) 

Setons and issues. These are ancient remedial means, 
in epilepsy. They have, no doubt, been employed 
with advantage, particularly in cases depending on' re- 
percussion of chronic cutaneous affections. Jn one in- 
stance, I have known a caustic issue on the back of the 
neck aggravate the disease greatly. Larrey speaks 
very favorably of bleeding from the back of the head, 
followed by blisters, moxas, or other counter-irritants, 
on and about the head. Tartar emetic ointment has, 
by its pustulating effects, cured this disease. (Creigh- 
ton.). The actual cautery was used by the ancients, 
and by Dc Ilaeriand Larrey among the moderns, with 
success, in this disease. 

The following composition has been employed, in this 
city, with decided benefit, in epilepsy. R. Pulv. Zin- 



170 CHOREA. 

giberis, Pulv. Salvia? officinal, P. Pern. Sinapi, i" a 3j. 
M. Dose three tea-spoonfuls every morning, fasting, 
wiih an occasional purgative. 
Music. Quarin cured a girl hy music. Other cases, to 
the same effect, are mentioned by Bruckman and Lich- 
tenthal. 

CHOREA. 

Chorea almost always occurs before or about the age 
of puberty — rarely beyond the twentieth year of age. 
It is always gradual in its approach. During the form- 
ing stage, the appetite is variable; sometimes ravenous; 
die bowels constipated; vertigo; palpitation of the 
heart; oppression and anxiety in the precordial re- 
gion; fulness and tension in the head, with occasional 
metnal confusion; cold feet; variable disposition; itch- 
ing in the nose, &,c. The first manifestations of the 
spasmodic affections are, slight, irregular motions of 
the muscles of the face, and an awkwardness in the 
gait — progression becoming starting and hobbling. 
The irregular involuntary actions gradually increase in 
violence and constancy, until the arms and legs are al- 
most in continual motion, and the countenance various- 
ly and uninterruptedly distorted. The voluntary mus- 
cles alone are affected. Like epilepsy, chorea, by long 
continuance, weakens and finally destroys the intellec- 
tual powers In very protracted cases, some degree of 
fever generally supervenes, and the muscles waste and 
become flaccid. During sleep, the irregular muscular 
contractions often cease. 

There is something very remarkable in the circumstance, that 
the irregular motions, which the utmost exertion of the will 
cannot control during the period of its activity, cease, when it 
is no longer operative during sleep. It would seem, -that the 
stimulus of volition is in some degree essential to the disease. 

Chorea occurs more frequently in girls than boys. In 
about twenty cases I have seen of this disease, there 



CHOREA. 



171 



was but one instance in which the patient was a male. 
Children of a nervous temperament, are most liable 
to the disease. 

Exciting causes. Intestinal irritation from various ex- 
citing substances lodged in the alimentary canal; fear 
and terror; repercussion of chronic cutaneous erup- 
tions ; cold ; suppression of catamenia. It is sometimes 
the consequence of typhous and other severe forms of 
fever. 

Proximate cause. I believe it to be essentially a cere- 
bral affection, because: 1. The voluntary muscles 
alone are affected : "2. The intellectual faculties soon 
suffer: 3. The loss of the power of volition over its le- 
gitimate dependencies. 

Prognosis. Not often fatal . When produced by worms, 
or other irritating substances in the intestinal canal, it 
generally yields, without much difficulty, to remedial 
treatment. When caused by cold, also, it is seldom 
very difficult to cure. 

Treatment. In plethoric subjects, with a super-excited 
state of the pulse, bleeding is proper. Generally, how- 
ever, sanguineous evacuations are not required. Pur- 
gatives are among the most valuable remedies we 
possess, in this disease. (Hamilton.) In a majority 
of cases, the bowels are infarcted with feculent 
matter, and this appears often to exist, as the primary 
cause of the disease; hence the utility of daily purga- 
tion, in many cases. When worms are the cause of 
the disease, anthelmintics, but particularly spirits of 
turpentine, with castor oil, are particularly beneficial. 
Tonics ought to be employed, in alternation with pur- 
gatives, unless contra-indicated by the state of the sys- 
tem. The cold bath, bitter infusions, sub-carbonate of 
iron, quinine, and flowers of zinc, are the tonics usu- 
ally employed. They are especially advantageous du- 
ring the period of convalescence. The nitrate of 
silver has been employed successfully in this disease. 
(Crampton.) Of the remedies that have been used 



172 TETANUS. 

with success, in this disease, arc the following. Che 
nopodium ainbrosoides. Dose bj. in powder, three 
. times daily. (Hufeland, Plenk.) Cardamine jrraten- 
.lis. The flowers are recommended by £ir G. Baker. 
Dose oj. Camphor, in combination with Valerian. 
*(\Vilson, Pitt.) Belladonna Stramonium, Opium, 
have been recommended, but have very properly fallen 
into disuse. Cuprum ammoniacum; Wilson relates 
cases that were cured with this article. (Lonrf. Med. 
Phys. Jour.') Electricity, very moderately applied, has 
done good. Rubefacients, bisters, tartar emetic oint- 
ment, along the course of the spine, are remedies of 
considerable power in this disease. The diet must be 
simple, unirritating, and digestible. 

TETANUS. 

Character. Tonic spasms of the voluntary muscles, — 
the powers of sensation and thought remaining unim- 
paired. 

Tetanus is divided into different varieties, viz: trismus 
opisthotonos, emprosthotonos, pleurolhotonos. In 
the first, the muscles of the jaw are chiefly affected ; in 
the second, the extensors of the back, producing recur- 
vation of the body; in the third, those on the anterior 
part, producing incur cation; and in the last, those on 
the side are principally affected, causing a lateral cur- 
vature. It is divided also into idiopathic and trau- 
matic — the former variety being the result of general 
causes — the latter, of external injuries. This division 
has an important bearing both on the prognosis and 
treatment of the disease. 

Symptoms. Its approach is almost always gradual, the 
symptoms being developed in the following order. 
Slight difficulty of deglutition and change of the voice; 
an uneasy sensation in the precordial region; stiffness 
in the muscles of the neck and jaws. These symptoms 
having increased to a considerable degree of violence, 



?ETANt7S. 173 

SUtlden painful retractions about theensiform cartilage, 
with simultaneous retraction of the head, occun De- 
glutition is painful and difficult, and re-excites the 
spasms. The spasms acquire more and more violence 
and frequency, until the retraction of the head, and ri- 
gidity of the whole body become truly frightful. Tfie 
mind is seldom affected ; the appetite generally remains, 
and digestion goes on regularly. Costiveness almost 
always attends. The muscles supplied with gangli- 
onic nerves, and those which mom the fingers, re* 
main free from spasm, until near the fatal termination 
of the disease. The disease usually terminates before 
the fifth or sixth day — sometimes it continues much 
longer; and occasionally it assumes a chronic form. 

Causes. Various injuries. Contused, lacerated, and 
punctured wounds, most apt to produce tetanus. A 
partial division or laceration of a nerve apt to excite it. 
The introduction of cold and damp air into gun-shot 
wounds, when casting off their slough, favors the intro- 
duction of tetanus. (Larrey.) The application of 
caustic to encysted tumours; compound fractures; the 
insertion of artificial teeth; amputation; ligatures, in- 
cluding nerves; cutting corns too closely, &,c. have all 
frequently produced the disease. Cold and damp 
night air, after fatigue and exposure to a high degree 
of atmospheric heat during the day, is the most com- 
mon general cause. Hence its frequency in tropical 
climates. Atmospheric heat a powerful predisposing 
cause of tetanus. Traumatic tetanus generally comes 
on about the eighth or ninth day after the infliction of 
the wound; frequently not until it is cicatrized. 

Proximate cause. Galen, Willis, Hoffman, Frank, and 
Burserius, referred the original seat of the disease to 
the spinal marrow, and this opinion obtains pretty 
generally at the present day. It is supported by the 
post-mortem appearances, and the circumstance, that 
the muscles, supplied by spinal nerves, are almost ex- 
clusively affected. 



174 TETANTTS. 

Prognosis. Traumatic tetanus, seldom cured. The 
idiopathic form, less difficult of cure. According to 
Parry, the disease always terminates fatally, when the 
pulse rises to 120 beats in a minute, on the first day; if, 
by the fifth day, it does not exceed J 10, a favcraLle 
issue may be expected. 

The favorable signs are: a very gradual supervention of 
the disease; abdomen not very hard; boweJs easily 
moved; moist and moderately warm skin; sound sleep; 
an increased flow of saliva; a natural expression of 
the countenance. When the majority, or all of these 
circumstances occur, we may entertain hopes of reco- 
very. The unfavorable sig:is are: a sudden and vio- 
lent invasion of the disease; great rigidity of the mus- 
cles of the back, neck, and abdomen; violent pain and 
retraction in the pit of the stomach; very hard and re- 
tracted abdomen; spasmodic twitches of the muscles of 
the neck and jaws, on firm abdominal pressure; hydro- 
phobic symptoms. (Morrison.) 

Treatment. Divided into prophylactic and curative — 
the former refers to the pretention,' the latter to the 
removal of the disease. Wounds or injuries from 
which tetanus is apprehended, should be brought to 
suppurate as soon as possible. For this purpose, sca- 
rification, free division with the knife, irritating appli- 
cations, such as spirits of turpentine, caustic, &,c. are 
employed. When the disease has made its appearance, 
constitationa are to be used conjointly with the local 
remedies. The most important of these are: — 

Blood-It ttiag, employed ad deliquium, in conjunction 
with mercury and opium, has cured the disease. (Med. 
and Phys. Jour. 1»2.1. — Medico Chir. Trans, vol. ii.j 

Purgatices always proper, as auxiliary means, particu- 
larly in trismus nasc^ntium. (Chalmers, Hamilton.) 

Opium, is one of the most efficacious remedies we possess 
in this disease. It must be given in large and frequent 
doses. Dr. Morrison, who was particularly successful 
with it, commenced with 100 drops of laudanum, and 



TETANIA 175 

increased each succeeding dose, by one third this 
quantity every two hours. 
Mercury, highly and deservedly recommended by many, 
in the treatment of this disease. It is more efficacious 
in idiopathic, than traumatic tetanus. It may be ad- 
vantageously used, conjointly with the warm bath, 
opium, :&c. 
Spirits of turpentine, has recently been successfully em- 
ployed by Drs. Hutchinson, Toms, and Mott. Dr. 
JYIott's case is a striking example of its usefulness in 
this disease. After the hot and cold baths, tobacco, 
opium, bark and wine, and blisters to the spine, had 
been fairly tried without benefit, a tea-spoonful oftur- 

psnline,gicen evenjfifteen minutes, relieved the spasms 
in two hours; and by continuing its use until 123 tea- 
spoonfuls were taken, the disease was perfectly removed. 

Wine, and other alcoholic liquors. This was a favo- 
rite remedy with Rush. Opium is now generally, and 
I think properly, preferred. When employed, it must 
be very freely given. Rush gave it in conjunction with 
bark and mercury. 

Tobacco, both by the mouth, and in the form of enemata, 
has been found decidedly beneficial. An interesting 
example of its efficacy, is related in the third volume of 
Dublin Hospital Reports, by Dr. O'Beirne. Dr. An- 
derson used tobacco baths, fomentations, and enemata, 
with success, in several cases. (Med. Chir. Traps, of 
Edinburgh, vol. i.) It must be employed with caution. 

Cold affusions, a very ancient remedy in tetanus. ( 1 iipp. 
Aphor. Lib. iv. Sect. v. Aph. %, and Lib. v. Sect. ii. 
Aph. 2 ! ) They were successfully used by Drs. Wright, 
Cochrane, and Currie. I have known a case cured 
by salivation and cold affusions, conjointly. 

Cantharides, given internally, has effected cures. Dr. 
Brown, (New York. Med. Repes. vol iv.) cured a 
case with this medicine. It should be given so as to 
produce stranguary. 

Prussic acid. Cases of its successful employment in 



176 WHOOPING COUGH. 

this disease, are related by Drs Pattison, and Trezevant. 

The warm hath* a useful adjuvant; it generally procures 
temporary relief .Some practitioners have found it to 
do harm ; particularly Dr. Hillary. The exertion and 
movement which it requires of the patient, is said, by 
Dr. Morrison, to do injury. 

Blist rs along the whole tract of the spine, have done 
much good in this disease; a more powerful, prompt, 
and efficacious means of this kind, however, is the ap- 
plication of caustic potash, as first recommended by 
Dr. Hartshorne of this city. (Eclectic Keper. vol. vii.) 
Whatever other remedies may be employed, the appli- 
cation of this caustic along the course of the spine 
should never be neglected. The cases which have 
been reported, illustrative of its efficacy are by no means 
few. 

The actual cautery along the spine, is said by Mursina, 
to have effected a prompt and perfect cure. The good 
effects which 1 have witnessed from the application of 
the actual cautery, in deep seated articular inflamma- 
tion, convinces me that there is no means in our pos- 
session, by which we can produce so prompt and pow- 
erful an impression on the inflammation of internal ca- 
vities and parts, as this potent agent. 

PERTUSSIS WHOOPING COUGH. 

Character. A contagious cough — paroxysmal, convul- 
sive, and suffocative; inspiration during the cough 
shrill — the cough frequently terminating in vomiting' 

'Whooping cough may be divided into three stages: I. 
The forming stage; characterized by the usual symp- 
toms of ordinary catarrh ; i. e. lassitude, weakness, and 
head-ache; sneezing; slight hoarseness; discharge of 
thin mucus from the nose; restless sleep; inappetency; 
and generally slight febrile symptoms; the cough is 
shrill, dry, and comes on in sudden but short parox- 
ysms, without whooping. This stage lasts from two 



WHOOPING COUGH. 177 

to three weeks: The convulsive stage; characterized 
by violent paroxysms of convulsive and suffocative 
cough, the inspirations being difficult and stridulous, 
and attended with a sense of obstruction or spasmodic 
stricture of the glottis. These paroxysms return at 
first five or six times daily, and gradually increase in 
frequency, so as, at last, to return almost hourly. The 
approach of a fit of coughing, is always announced by 
a sense of stricture in the breast, and titillation in the 
larynx and prsecordise. The paroxysm lasts from a 
half to four or five minutes, and terminates by vomiting, 
or the discharge of a large quantity of viscid mucus 
from the bronchia. Pain is felt in the breast, immedi- 
ately after the cough. The duration of this stage is 
very various: in general it lasts from four to six weeks: 
3. The stage of declension; this stage begins, when 
the spasmodic and suffocative character of the cough 
begins to abate. The declension of the disease is al- 
ways very gradual; its duration is as various as that of 
the other stages — commonly from two to four weeks. 

Prognosis. Whooping cough is seldom fatal, except by 
the supervention of bronchitis, hydrocephalus, cynanche 
trachealis, pneumonia, convulsions, or marasmus. — , 
Sequellce. Glandular swellings, dropsy, epilepsy, op- 
thalmia, struma, rickets, general cachexy, phthisis, &c. 

Proximate cause. The opinions on this subject are ex-? 
ceedingly various. Marcus, Whatt, and others, re- 
gard it as a peculiar species of bronchial inflamma- 
tion. Webster regards the brain as its primary dis- 
ease. Albers considers it as depending on a peculiar 
irritation of the eighth pair of nerves. Some view the 
stomach as its original location; and others regard it 
as a spasmodic disease, allied to asthma, My own 
opinion coincides with that of Albers. My reasons for 
rejecting the doctrine of its being an inflammatory af- 
fection, are stated in the lecture. The inflammatory 
symptoms which frequently occur in this disease, are 
not essential, but accidental to the disease. In many 



178 WHOOriNO COUGH. 

cases, not the slightest febrile symptoms occur; and 
when we reflect on the almost constant agitation and 
irritation which the lungs suffer from the cough, we 
have good grounds for believing, that the inflamed ap- 
pearance of the mucous membrane of the bronchia, 
so commonly found on post-mortem examination is the 
effect, and not the cause of the disease. 

Treatment. It is generally believed, that whooping 
cough, like the exanthematous fevers, cannot be arrest- 
ed in its course, but that, when once developed, it ne- 
cessarily passes through its different stages. This 
I hold to be an erroneous opinion, being thoroughly 
persuaded, that it is susceptible of being arrested at 
any time, whether in its forming, convulsive, or de- 
clining stage. 

Bleeding and leeching. Both may be employed with 
decided advantage, in cases accidentally complicated 
with inflammatory symptoms, or where much cephalic 
congestion exists. The disease cannot, however, be 
subdued by them. 

Purgatives of the mild kind, are proper, in cases attended 
with constipation, a loaded state of the bowels, or pre- 
ternatural determination to the head. 

Emeties, always beneficial, unless great gastric irritability 
exists. They free the bronchia and trachea of the 
viscid mucus with which they are loaded, and perhaps 
do good by their impressions on the pneumo-gastric 
nerves. 

Narcotics. Belladonna is a valuable remedy. It is 
much used in Germany and France. I have em- 
ployed it in a number of cases, with great advan- 
tage. Dose for a child under one year, 1-2 grain; 
from two to three years, 2 1-2 grains of the powdered 
root. Conium maculatum, rhus vernix, hyoscya- 
mus, opium, lactuca mrosa, Pulsatilla nigricans, and 
solatium nigrum, have all been used and praised as 
remedies in this disease. 

Antispasmodics. Assafoetida in emulsion, useful, where 



WHOOPING COUGH. 179 

410 symptoms of febrile irritation exist. Musk, valeri- 
an, amber, castor, &,c. have been beneficially employ- 
ed. Not a great deal, however, is to be expected from 
this class of remedies. 

Tonics. Cinchona, quinine, flowers of zinc, and arse- 
nic, are remedies of much value, where no signs of in- 
ternal inflammation exist. I have given large doses of 
quinine, with marked advantage. 

Expectorants, are seldom of much service. Pearson's 
alkaline solution, and Kerme's mineral, suspended in 
in a mucilaginous fluid, are among the best of this class 
of remedies. 

Lobelia inflata. I have found the tincture of this plant 
a most valuable remedy in whooping cough. From 
ten to fifteen drops are to be given, four times daily, to 
a child between the first and second years of age. 

Tinct. Cantharides, highly recommended by Armstrong, 
Chalmers, Millar, Buchholz, Loder, Lettsom, Hufe- 
land, and others. It must be used until slight ardor 
urinse occurs. 

External applications. Frictions, with tartar emetic 
ointment, along the spine, or over the precordial r&° 
gion, will generally prove decidedly useful. This prac- 
tice originated with Autenrieth. (Richter.) Blisters 
and rubifacients are indispensable, when pulmonic in- 
flammation exists. 

Balsam Copaiva, is a remedy of inestimable powers, 
when the disease has degenerated into chronic bron- 
chitis, and the expectoration is puruloid. 

Inhalations. The inhalation of balsamic vapors, the 
nitrous acid vapor, and the vapor of tar, are strong- 
ly recommended by some recent writers. 1 have used 
the nitrous acid vapor with benefit, in several violent 
cases. 

The diet should be simple and unirritating ; and great 
care must be taken against the influence of cold and 
damp weather. 



180 ASTHMA. 



ASTHMA. 



Character. Great difficulty of breathing, attended with 
a sense of suffocation, great thoracic constriction, 
Wheezing, and cough. 

Symptoms. The attack usually preceded by premonitory 
symptoms; such as drowsiness; head-ache; itching of 
the skin; flatus; heart-burn; acid eructations; sickness; 
fulness and anxiety about the prsccordia; weight over 
the eyes, &,c. 

The paroxysm generally comes on at night, during sleep. 
It is characterised by inexpressible anxiety ; very labo- 
rious wheezing, and suffocative breathing; great tight- 
ness about the chest; countenance bloated and Iivid ; — • 
— sometimes pale; cold extremities; intense desire for 
cool fresh air; incapability of lying down; pulse fre- 
quent, irregular, and often intermitting; abdomen dis- 
tended with wind; cough, at first dry; a copious expec- 
toration of viscid mucus occurring in the course of 
some hours, bringing with it considerable temporary 
relief The symptoms remit greatly, during the ensu- 
ing day. On the next night, however, the fit generally 
returns. In this manner, it often goes on with remis- 
sions by day, and exacerbations by night, for five or 
six days; and sometimes much longer. 

Predisposition. The disease rarely occurs before the 
age of puberty. The predisposition appears to consist 
in an irritable and weak condition of the respiratory 
organs. It seems, in some instances, to be hereditary. 
Persons of weak muscular power, and disposition to 
obesity and corpulency, arc most liable to the disease. 

Exciting causes. Particular conditions of the atmos- 
phere, in relation to its humidity, electricity and tem- 
perature; various irritating substances conveyed to the 
lungs ; suppression of accustomed discharges ; reper- 
cussion of cutaneous affections; metastasis of gout or 
rheumatism; general plethora; gastric and intestinal 



ASTHMAi 18 i 

irritation; derangement of the digestive functions; cer- 
tain odours ; indigestible aliment ; anger, and terror. 
Authors have divided asthma into a great many varie- 
ties. It does not appear to me, that these distinctions 
are of any practical utility ; although it is unquestion- 
ably of much importance to attend to the nature of the 
exciting cause, in prescribing for the disease. 
Proximate cause. The opinions on this subject very 
various. Cullen ascribed it to a preternatural spasmo- 
dic constriction of the bronchiae. Parry to a vascular 
fulness of the bronchial membrane, by which the air 
cells are mechanically diminished. Potter, to general 
venous congestion of the lungs. Bree, to an irritation 
seated within the air cavities, caused by a viscid and 
irritating serum. My own opinion is, that it depends 
on a peculiar irritation of the pneumogastric nerves, in 
consequence of which* the regular transmission of the 
nervous influence to the lungs, is interrupted. This 
Opinion is founded: 1. On the effects which are pro- 
duced on respiration, by dividing the eighth pair of 
nerves, which entirely resemble the phenomena of 
asthma: 2. The suddenness with which the spasmodic 
breathing may often be allayed, by certain medicines, 
as the lobelia inftata: and, 3. The beneficial effects 
resulting from the transmission of the galvanic influx 
ence through the lungs. 
Treatment. Bree affirms, that we can do but little tow- 
ards mitigating the paroxysm. He is wrong; I have 
often seen the paroxysm arrested, in less than thirty 
minutes. 
Bleeding. When the disease arises from the suppression 
of some habitual evacuation, and is attended with ge- 
neral plethora, blood-letting is indispensable. When- 
ever the pulse is hard and tense, blood should be drawn. 
Emetics, are much recommended by some. When gas- 
tric irritation exists, from indigestible diet, or other 
causes, they are serviceable* Under other circum- 
stances, they seldom do much good . 



182 AiTHMA. 

Purgatives beneficial, when the bowels are disordered. 
Bree recommends chalk, in union with rhubarb. 

Expectorants, a useful class of remedies in this disease. 
Floyer regarded vinegar of squills as a specific in this 
disease, which, however, it is very far from being. 

Diuretics, are serviceable, in dropsical habits. A copi- 
ous flow of urine, is always a favorable occurrence. 

Antispasmodics, are seldom useful. In habitual or 
chronic asthma, opium with ether, has been found bene- 
ficial. 

Narcotics. Hyoscyamus, stramonium, tobacco, and opi- 
um, have been recommended. They are occasionally 
palliative, particularly in protracted or habitual cases. 
The root of the stramonium is to be cut fine, and 
smoked in a pipe. 

Symplocarpus fatida. I have known the infusion of the 
root of this plant, give great and prompt relief. 

Lobelia inflata. I regard this vegetable as decidedly the 
most valuable remedy we possess, for arresting or miti- 
gating the asthmatic paroxysm. My own experience 
corresponds entirely with the statements published by 
Drs. Thatcher, Stewart, Cutler, and others, of its valu- 
able remediate effects in this disease. I have known a 
violent fit of ashma completely allayed in the course of 
thirty minutes. 

Coffee. A cup of very strong coffee will often procure 
much alleviation in this complaint. (Percival.) 

Digitalis, in combination with small doses of opium, re- 
commended by Drs. Ferriar and Percival. 

Prussic acid, employed with advantage by Drs. Oliver 
and Granville. 

Galvanism has of late years been employed with much 
advantage in this complaint, by Dr. Philip and others. 
The galvanic influence must be communicated with 
much force. The two wires of a weak galvanic 
trough, are to be attached, one to a piece of metal 
placed on the pit of the stomach, and the other on the 
side of the neck, over the par vagum. 



ANGINA PECTORIS. 183 

The prophylactic remedies are of the tonic kind. Bark, 
iron, tonic bitters, with occasional mild aperients, mode- 
rate exercise, and above all, a light and digestible diet, 
with the use of the cold shower bath, are to be used 
during the intervals of the attacks. 

ANGINA PECTORIS. 

Symptoms . Sudden and violent pain about the sternum, 
extending to the arms, attended with great anxiety, dif- 
ficulty of breathing, and a sense of suffocation ; pulse 
seldom materially affected — sometimes irregular or in- 
termitting ; countenance pale and expressive of intense 
anxiety; extremities cold. The attack usually comes 
on while the patient is walking. At first, it lasts but a 
few minutes, and returns after long intervals ; but by 
degrees the fits recur oftener , and become more pro- 
tracted. 

Predisposition. It occurs more frequently in males than 
females; and exceedingly seldom in young persons. 
Subjects of a gouty or rheumatic habit, with a tendency 
to corpulency, are most liable to the disease. 

Causes. Ossification of the coronary arteries, and 
valves of the heart ; dilatation of its ventricles ; a soft- 
ened structure of the heart, and other organic affec- 
tions of this organ, and of the adjoining parts. In some 
cases, however, not the slightest traces of structural de- 
rangement are found on dissection. Dr. Johnson thinks, 
that a neuralgic affection of the cardiac plexus may 
produce it — an opinion which is, I think, well founded. 
From all that has been ascertained in relation to this 
subject, it would seem, that angina pectoris is an affec- 
tion which may be excited by a variety of causes; and 
it appears to me probable, that the essential nature of 
the disease, consists in an irritated condition of the 
cardiac nerves. 

Prognosis. The disease is generally believed to be in- 
curable ; and when it depends on structural derange- 
ment of the heart, it undoubtedly is so. There are 



184 DROPSY. 

some well attested cases on record, however, which 
yielded to remedial measures. Death almost always 
occurs suddenly. Fothergill, Wichmann. 
Treatment. For the relief of the paroxysm, bleeding, 
opium, hyoscyamus. a recumbent posture, and perfect 
rest and quietness, are often found beneficial. To pre- 
vent the return of the disease, the following remedies 
have been employed with advantage. Guaiacum; 
opium, musk, and camphor in union, (Shaefer ;) cicuta, 
assafoetida, and camphor, (Johnson ;) flowers of zinc 
and opium, (Perkins;) lime water and antimony, 
(Smith ;) Frictions with tartar emetic ointment on the 
breast, (Godwin;) phosphoric acid, (Baumes,Richter;) 
James's powder, (£mith ;) a rigid antiphlogistic regi- 
men, (Oclier;) arsenic, (Hufeland, Blane;) prussjc 
acid ; hyoscyamus ; stramonium ; cuprum ammoniacum, 
&c. All kinds of spirituous drink are injurious; so 
are strong mental emotions; inordinate venereal indul- 
gence ; strong corporeal exertions ; sudden atmospheric 
vicissitudes ; indigestible and irritating articles of food, 
&c. 



CHAPTER XVIII. 



DROPSY. 



Pathology of Dropsy. Dropsical effusion is not, pro- 
perly speaking, a disease, but only an effect of disease. 
The morbid condition upon which the dropsical effu- 
sions depend, is either inflammation, or a state of the 
exhalents closely allied to inflammation. (Rush.) 
The doctrines which allege, that torpor of the absorb- 



ANASARCA. 185 

ents, or relaxation of the exhalents, is the proximate 
cause of the effusion, are examined, and their insuffici- 
ency pointed out. There is, no doubt, always deficient 
venous absorption, — because that condition of the ca- 
pillaries, which disposes to excessive exhalation, js es* 
sentially connected with a congested state of these ves* 
sels, and congestion, or vascular fulness, always im- 
pedes absorption. (Magendie.) Observations on the 
character of the urine, in hydropic diseases. In some 
instances, the urine contains more or less serum ; in 
others, it is entirely destitute of it. According to the 
observations of Blackall, Willis, and Ayre, it is in the 
subacute and idiopathic forms of dropsy, that the urine 
js loaded with the greatest quantity of serum. In 
dropsy from scarlatina, there is generally a large quan* 
tity of serum in the urine. In local dropsies, not atten- 
ded with general excitement, the urine is seldom 
charged with any serum. (Ayre,) 

When the heart sympathizes with the local or general 
morbid action of the exhalents, febrile symptoms at* 
tend. When the morbid excitement of the exhalents 
does not extend to the heart, the general circulation is 
languid, and debility and relaxation characterize the 
disease. 

The general indications in the treatment of dropsy, are? 
2. To procure the absorption and elimination of the 
effused fluid: 2. To correct the morbid action of the 
serous exhalents, from which the effusion takes place. 

Dropsy is divided into three principal varieties: viz. Ana- 
sarca, ascites, and hydrothorax. 

ANASARCA. 

In this variety, the effusion takes place into the cellular 
tissue. It may be either local or general. A part that 
is anasarcous, pits on pressure. It almost always be* 
gins in the feet or legs — the swelling diminishing dur* 
ing the night, and increasing towards evening. The 



186 ASCITES. 

urine in this, as in the other varieties of dropsy, is al- 
ways scanty and high colored ; the countenance is sal- 
low, the general system sluggish, and there is usually 
much sleepiness. Anasarca is frequently connected 
with effusion into the abdomen and chest. 

Causes. Local anasarca may be produced, by whatever 
impedes the return of the blood from a part — as, indu- 
rated glands pressing on large veins, ligatures, &c. It 
arises also from mere general debility; diseases of the 
heart; phthisis, &c. 

General Anasarca may result from hemorrhages, diar- 
rhoea, diabetis, and other circumstances that rapidly 
exhaust the system. Observations on the manner in 
which these causes produce dropsy. Sudden suppres- 
sion of perspiration, particularly after scarlatina, 
measles, or while under the influence of mercury, a 
frequent cause of general anasarca. Dropsy from this 
cause always decidedly phlogistic. General anasarca 
may also result from the internal use of arsenic — from 
torpor of the kidneys — from amenorrhoea, general ple- 
thora, with a relaxed habit, chronic diseases, intestinal 
irritation, &c. Observations on the modus operandi 
of these causes. 

Proximate Cause. A sub-inflammatory action of the 
exhalents of the cellular tissue, attended with increased 
exhalation, and diminished venous absorption. It ap- 
pears to me probable, that congestion in the venous 
capillaries, performs an important part in the produc- 
tion of dropsical accumulations. This idea is discussed 
at length, in the lecture. 

ASCITES. 

Abdominal dropsy. Its causes are sometimes local, at 
pthers general. The local causes are such as impede 
the circulation through the portal system of vessels — 
among which, visceral indurations, particularly of the 
liver and spleen, are the most common. Dr. Ayre de- 



HYBROTHOftAX. 187 

fries that visceral obstructions produce dropsy; they 
notwithstanding frequently do so. The most common 
general cause of ascites, is cold, either generally or lo- 
cally applied. When the result of this cause, its cha- 
racter is always conspicuously inflammatory ; the blood 
usually exhibiting the buffy coat; the skin being dry 
and hot; the pulse frequent and tense, and the urine 
loaded with serum. Ascites is seldom wholly free from 
anasarca. Intestinal irritation sometimes gives rise to 
abdominal dropsy. It occurs as the sequel of peritoni- 
tis. Diagnosis. 

Proximate cause. A morbid action of the exhalents of 
the peritoneum, attended with capillary congestion, 
and diminished venous absorption. 

HYDROTHORAX. 

Serum effused into the cavity of the thorax. It is charac- 
terized by the following 

Symptoms. Oppression in the chest ; difficult respira- 
tion, particularly when lying down, or ascending 
heights; dry cough; a sense of suffocation, when in a 
recumbent position; sudden starting during sleep; 
pulse intermitting, or irregular; thirst considerable} 
urine scanty; oedema of the feet; a pale bloated coun- 
tenance, &c. Divided into symptomatic and idiopa- 
thic. The first arises from organic affections, — the 
latter from general causes. 

Causes. Organic affections of the heart. When from 
this cause, the effusion occurs on both sides. Chronic 
pleuritis, a frequent cause of hydrothorax. It may 
also result from a tuberculous state of the pleura, and 
even from structural disease of the stomach and liver. 
This is by far the most frequent variety of hydrotho- 
rax, and is almost always incurable. 

Idiopathic hydrothorax, is of very rare occurrence, and 
generally easily cured. The effusion almost alway* 



188 



HYDItOTHOKAX. 



occurs only on one side — that side becoming sometimes 
considerably enlarged, by the pressure of the fluid. 

General plethora, predisposes to hydrothorax; particular- 
ly in persons who have passed the middle period of 
life, and who indulge in the pleasures of the table, and 
use but little exercise. 

Diagnosis. A sense of suffocation on lying down, and 
on firm pressure on the abdomen, will generally distin- 
guish it from mere organic disease of the heart. Per- 
cussion produces a dull sound, and the stethescope 
detects the absence of the respiratory murmur. 

Treatment. When the heart sympathizes with the 
primary local irritation, or with the morbid action of 
the capillaries from which the effusion occurs, blood-* 
letting is an important remedy. It is indicated in all 
cases, in which there is tension and quickness of the 
pulse. Local bleeding* from the thorax or abdomen, 
recommended by Ayre, in hydrothorax and ascites* 

Diuretics, are important remedies in hydropic diseases. 
Their operation is, however, rather palliative than cu- 
rative — that is, they evacuate the effused fluid, rather 
than correct the morbid action on which the effusion 
depends. In full and phlogistic habits, their operation 
is promoted by bleeding and cathartics. When the 
effusion is very extensive, and the blood has been de- 
prived of a great portion of its serum, copious draughts 
of water promote the operation of diuretics. The 
mode in which diuresis removes dropsical effusion ex- 
plained. The most useful diuretics in dropsy, are: 
squills, digitalis, tobacco, cantharides; acetate, nitrate, 
and tartrate of potash; colchicum, wild carrot seed, 
erigeron heterophyllum, and juniper berries. 

The squill, is the best diuretic in hydrothorax. It is best 
adapted to cases in which the urine is very scanty, 
high colored, and sedimentous, and not attended with 
much febrile excitement. Its virtues are much enhanc- 
ed, by giving it in Union with calomel, especially in 
hydrothorax. Very advantageously combined with 



jgypROTHORAJS. 180 

digitalis and nitre. The reason why calomel and 
squills, in combination, are more beneficial in hydro- 
thorax, than in the other varieties of dropsy, are three- 
fold; "1. absorption; 2. diuresis; 3. determination to 
the glands of the mouth and throat, causing a deriva- 
tion from the vessels of the pleura." 

Digitalis. Some greatly extol its virtues in dropsy— oth- 
ers speak lightly of it. It does not appear to do much 
good, in subjects of a tense fibre, and robust habit of 
body. In persons of a contrary habit, with a pale 
countenance, cold skin, and weak pulse, it often proves 
decidedly beneficial, (Withering, Maclean.) Digi- 
talis, is the best diuretic in dropsies following scarla- 
tina. It is almost always beneficial, when the urine is 
coagulable by heat, small in quantity, somewhat tur- 
bid, and depositing a branny sediment, when cold. 
(Blackall.) It falmost always fails to do good, when 
the urine, though serous, is pale, crude, and without 
sediment. It is generally given, in combination with 
squill or calomel. I prefer giving it in union with nitre 
and calomel. In feeble habits, it may be advantageous- 
ly combined with opium. 

Cantharides, more particularly useful in anasarca, after 
scarlatina. (Ferriar.) Nitre is an excellent remedy, 
when the febrile excitement runs high. Diuretic 
drinks, such as infusion of juniper berries, wild carrot 
seed, &,c. should be freely allied. 

Cathartics. Valuable remedies in ascites and anasarca 
— 'hot so in hydrothorax. Their modus operandi ex- 
plained. The articles of this class, *most beneficial, 
are ; tartrate of potash ; elaterium ; gamboge, &c Of 
these the tartrate of potash is both the safest and 
the most useful. I have employed the following diu- 
retic composition, with more uniform, and prompt 
advantage, than any other article, or combination of 
articles I have ever tried. R. Tart, potas. 3iss. Sulph. 
potas. 3ss. Pulv. Scillse, 3ij. Tart. Antimonii, gr. ij» 
Dose, a tea-spoonful, four or five times daily. This 



190 HXDROTHORAX. 

rarely fails to excite very copious watery stools, and at 
the same time, free diuresis. It is particularly useful 
in ascites. I have generally derived much more bene- 
fit from gamboge, than from elaterium. It is particu- 
larly useful in ascites. It may be advantageously com- 
bined with cream of tartar, in the proportion of 2 grains 
of the gamboge, to 30 of the latter article, repeated 
every three or four hours. It produces copious watery 
stools. 

Mercury, is a remedy of valuable powers in hydropic 
diseases. Generally given in uuion with diuretics, par- 
ticularly squills and digitalis. Should be given until 
the mouth is slightly affected by it. Relaxed and scor- 
butic habits, inimical to its beneficial influence. Es- 
pecially valuable, where there is organic disease of 
the liver. 

Sulphuret of Iron. I have seen much good done by 
this article, in cases attended with a relaxed and very 
debilitated state of the system; particularly in the ana- 
sarca of females, from excessive sanguineous discharges. 
It acts as a powerful diuretic, as well as tonic. 

Diaphoretics, are indicated, when the disease is the con- 
sequence of suppressed perspiration from cold. Anti- 
monials, in such cases, act beneficially. 

Blisters, and rubifacients, to the chest or abdomen, in 
hydrothorax and ascites, are strongly recommended by 
Ay re. I have seen much good derived from a blister 
over the abdomen, in a case of ascites. Tapping. 

DIARRH03A. 

Character. Frequent feculent stools, generally copious, 
always more liquid than natural, commonly attended 
with griping, but free from tenesmus and fever. 

Causes. Some act directly on the alimentary canal ; oth- 
ers indirectly, through the medium of the general sys- 
tem. Of the former kind, are: indigestible and irritat- 



DIARRHOEA. 191 

ing articles of food; acrid secretions ; worms ; acid, and 
other irritating substances received into the stomach. 
Among the more general causes, are: dentition; cold, 
particularly when connected with humidity; the re- 
percussion of cutaneous eruptions; various general and 
local diseases, as phthisis, affections of the liver, &c. It 
may also be excited by violent mental emotions, as ter- 
ror and grief 
Proximate cause. An increased irritability of the in- 
testines, giving rise to increased peristaltic motion. In 
protracted cases, the mucous membrane of the intes* 
tines is generally in a state of chronic inflammation, 
and frequently more or less ulcerated. (Broussais, 
Abercrombie.) According to Broussais, when diar- 
rhoea continues beyond the thirtieth day, it almost in- 
variably depends on organic disorder of the mucous 
membrane of the colon. He asserts, that chronic in" 
flammation of this membrane exists in all cases. This 
is doubtful. When ulceration exists, it is always most 
conspicuous in the ceecum, and the lower part of the 
colon. 
Treatment. The principal indications are: to subdue 
the irritability, or phlogosis of the bowels ; and to re 
move as much as possible, all local irritating causes. 
These indications are to be fulfilled: J. by determining 
the circulation to the surface, and thereby lessening 
the afflux of blood to the vessels of the intestines; and, 
2. by prescribing the most simple and unirritating arti- 
cles of food. To allay intestinal irritability, and deter- 
mine to the surface, opium, with small doses of calo- 
mel, or of ipecacuanha, and minute portions of calo- 
mel alone, are excellent remedies. Mild laxatives 
should be premised. In the diarrhoea of children, at- 
tended with a tumid and hard abdomen, laxatives are 
our principal remedies. Astringents, with mild to- 
nics, useful, in diarrhoea from mere debility of the 
stomach. Astringents improper, where there is much 
griping and tenderness of the abdomen, and in all in- 



192 CHOLERA. 

veterate cases. Absorbents proper, when acidity is 
the cause. Balsam Copaiva, on excellent remedy in 
very protracted and obstinate cases. I have used spi. 
rits of turpentine with much advantage, in such cases, 
A flannel roller round the abdomen, beneficial in all 
cases. A farinaceous diet is of the utmost consequence. 

CHOLERA, 

Character. Frequent and violent vomiting and purg- 
ing, with severe griping and cramps in the extremities. 

Symptoms. Its attack is almost invariably sudden.— 
There is at first pain and tension in the epigastric re- 
gion — followed soon by colic pain about the umbilical 
region, attended with nausea, upon which vomiting 
and purging speedily ensue, The discharges are at 
first watery and without bile; nor is there often bile 
thrown from the stomach, in the commencement. Af- 
ter the disease has continued for some time, however, 
bile appears in the evacuations. The most distressing 
symptom, is the excessively severe cramps which oc- 
cur in the abdominal muscles, and the extremities, in 
violent cases. Cholera seldom continues more than 
24 hours — it often terminates in death, within two 
hours. 

Causes. A superabundance of bile in the stomach, is 
not, as was formerly, and is still thought by many, the 
immediate exciting cause of cholera. There is, on the 
contrary, a. deficient secretion of bile — the liver being 
in an inactive and congested condition. The torpor 
of the liver, is generally in direct proportion to the vior 
lence of the disease. (Johnson.) 

Treatment. The principal indications are: to allay 
the morbid irritability of the alimentary canal ; to re-r 
store the regular action of the skin and liver; and to de- 
termine the circulation from the internal to the external 
parts. At first, bland diluents are proper. Opium in 
large doses, either alone, or in combination with calo? 



colic. 193 

mel; sinapisms to the abdomen ; the warm bath; spiced 
brandy; nitric acid vesication ; and anodyne injections; 
are the remedies upon which our dependence must 
be placed. Of these remedies, opium largely given, 
and sinapisms to the abdomen, are decidedly the most 
efficacious. Calomel should be given with the opium. 
Calomel is a valuable remedy, by itself; half a grain 
should be given every half hour. Bleeding has been 
useful in the Asiatic cholera. It is seldom indicated 
in the disease, as it occurs in our climate. 

colic. 

Colic is divided into several varieties, according to the 
nature of the exciting causes. 

Flatulent colic, so called from the prominent symptoms 
of indigestion and flatulency which attend. It is pro- 
duced by irritating and indigestible articles of diet. — 
Debility of the digestive organs, predisposes especially 
to this variety of colic. The colic pains come on, an 
hour or two after the indigestible diet is taken. Some- 
times the food passes into the bowels in an imperfectly 
digested state, and then the pain does not come on so 
soon, and is felt low down in the abdomen. At first, 
there is a sense of distention in the pit of the stomach, 
followed soon by pain, which rapidly increases, until it 
acquires an intense degree of violence. The pain oc- 
casionally remits. During the exacerbations, the pa- 
tient throws himself about, and presses firmly on his 
abdomen with his hands. Large quantities of air are 
from time to time forced up, or pass off downwards. 

Diagnosis. Distinguished from enteritis, by the agita- 
tion of the patient; by the relief obtained from abdomi- 
nal pressure, and by the pain frequently remitting. In 
all these respects, the reverse obtains in enteritis. 

Prognosis. Generally not dangerous, unless it termi- 
nates in inflammation, which sometimes, though not 
often, occurs. It sometimes produces a paralytic state 



194 COLIC. 

of a portion of the bowels, giving rise to habitual cos- 
tiveness. 
Treatment. In slight attacks, carminatives and ano- 
dynes are often sufficient to procure relief Remedies 
of this kind generally answer well, when the stomach 
does not contain any irritating substances. When it 
does contain irritating substances, an ipecacuanha 
emetic must be given. Purgatives to be used when 
the pain is below the stomach; they may be advanta- 
geously combined with aromatics. 1 prefer castor oil 
and spirit of turpentine, in union. Enemata, always 
useful. Where the pain is excessive, opium, in very 
large doses, with calomel, is a valuable remedy — it 
does not materially impede the subsequent operation of 
the necessary purgatives. 

Bilious colic, so called, from the bilious vomiting, and 
other symptoms, manifesting functional derangement 
of the liver. 

The more urgent and peculiar symptoms of this variety 
of colic, are generally preceded by head-ache, want of 
appetite, bitter taste in the mouth, thirst, and bilious 
vomiting. The colic pains are excessively acute ; pres- 
sure at first gives relief; but the abdomen becomes ten- 
der to the touch, as the disease advances. Immediate- 
ly after vomiting, the pain suffers a temporary abate- 
ment. The bowels are generally immoveably torpid. 
About the second or third day, the eyes and skin be- 
come yellow. Tremor, numbness, and paralysis of 
the arms, occasionally occur in this disease. Eructa- 
tions are common, and afford temporary relief 

Causes. Marsh miasmata. It occurs most commonly 
during the autumnal months, particularly after a long 
continuance of hot and humid weather. It may, how- 
ever, be produced also by causes of a sporadic character. 

It is generally believed, that the liver is in a state of mor- 
bid activity — that it secretes a superabundance of bile. 
Dr. Staly contends, that the liver is torpid — that there 



colic. 



195 



is a deficiency of bile. I have come to the same con- 
clusion. 

That there is functional derangement of the liver in this vari- 
ety of colic, does not admit of a doubt; but I do not believe the 
biliary secretion superabundant, but on the contrary diminish- 
ed and vitiated. That this is the case, may be inferred from 
the analogy which subsists between bilious colic and cholera 
morbus. Dr. Gregory observes that bilious colic is closely 
allied to cholera, occurring along with it, and apparently dif- 
fering from it only in some unessential features . Now it ap- 
pears to be well established, I think, that in cholera, the liver 
is far from being over-active — that it is, in fact, in an engorged 
and torpid condition, secreting but a very small portion of 
bile. Excessive irritability of the stomach, and torpor, with 
congestion of the liver almost always appear in connexion with 
each other. We have a further support for this opinion, in 
the fact, that, whenever the alvine discharges become bilious, 
an amendment takes place. 

Treatment. The principal indications are: 1. To free 
the bowels from their irritating contents: 2. To allay 
the irritability of the stomach and bowels : and, 3. To 
restore the healthy action of the liver. Emetics are 
very useful in the beginning, when there is not full 
spontaneous vomiting. Purgatives are of primary im- 
portance. They can seldom be given, however, with 
effect, until the gastric irritability is allayed. £mall 
doses of calomel, 1-2 grain — given every half hour, 
answer well to prepare the stomach for the reception 
of purgatives. Our principal reliance must be placed 
on the full operation of purgatives. Opium, given in 
full doses, affords much advantage after free purging; 
it should always be given in combination with calomel. 
Mild aperients to be used, for several days after the 
bowels have been once freely evacuated. Epispastics, 
sinapisms, and warm fomentations, are valuable aux- 
iliaries. Bleeding must be fully employed in robust 
and plethoric subjects, with the view of obviating in- 
flammation. Alkaline remedies are proper, when acid 
exists in the prima? viae ; magnesia is the best article of 
this kind. The warm bath, is a useful auxiliary. The 



1S6 COLICA PJCTONUM. 

utmost caution is to be used in relation to diet and ex- 
posure, during the period of convalescence. There 
are few diseases which are so apt to return, from errors 
in these respects, as the present one. Flannel should 
be worn round the abdomen. Very cold drinks must 
be avoided, during convalescence. 

COLICA PICTONUM. 

This variety of colic is known by various names; as, 
painter 's colic, dry gripes, Devonshire colic, colica 
pictavensis, rachialgia metallica, and saturnine colic. 

The disease generally comes on gradually, and is gene- 
rally preceded by symptoms of gastric derangement 
such as irregular appetite; constipation; foul eructa- 
tions; transient pains in the abdomen; languor; pale 
countenance, &c. This variety of colic is attended 
with constant and extremely severe pain about the um- 
bilical region ; the abdominal parieties are hard, and 
forcibly retracted; and the bowels almost immoveably 
constipated. The pain suffers occasional remissions, 
but no perfect intermissions, as in the other varieties 
of colic. It sometimes assumes a chronic form, pro- 
ducing wasting and palsy of the fore arms. The 
predisposition to it is greatly increased, by having once 
suffered an attack. 

Causes. Lead; hence its frequency with painters, 
glaziers, and workers in lead factories. Sudden at- 
mospheric vicissitudes, (Larrey ;) new and sour wines ; 
unripe fruits, &c. 

Treatment. The indications are: 1. To obviate inflam- 
mation: "2. To relieve the spasms of the bowels: and, 
3. to evacuate them. 

Bleeding should be freely employed in robust and ple- 
thoric subjects — or when the pulse is hard, quick, and 
tense. Opium with calomel, is a remedy of primary 
importance. Both these articles should be given in 
very large doses, with the view of relieving the intesti- 



DIABETES 197 

nal spasm, and bringing on an early mercurial action* 
Two grains of the former, with the same quantity of 
the latter, may be given every two hours, until the pain 
and spasms are relieved. Purgatives to be given after 
the opiates. They seldom fail to excite purging, as 
soon as the gums are affected with the mercury, and 
when preceded by very full doses of opium. Purga- 
tives should be given in a liquid form. Cold water, 
dashed on the abdomen and thighs, has been found 
usefuUn promoting the operation of cathartics. Alum, 
in fifteen grain doses, every three hours, much recom- 
mended by Richter. Stimulating enemata, highly be- 
neficial. The warm bath, a useful auxiliary. To re- 
lieve the paralysis and other sequella?, mercury is the 
best remedy. Nitrate of silver has also been success- 
fully used, for the relief of the paralysis. Pemberton's 
splinU 

DIABETES. 

This disease consists in the secretion and voiding of an 
unusually large quantity of urine, attended with a very 
dry skin; great thirst; slight febrile movements; vora- 
cious appetite ; a sense of weight and uneasiness in the 
stomach; white and foul tongue: great lassitude; pain 
and weakness in the loins; irregular bowels; cold feet; 
dull and heavy eyes ; and towards the last, great wast- 
ing of the flesh, and debility; vertigo; head-ache ; diffi- 
culty of breathing; spongy gums; offensive breath; 
constant drowsiness; and hectic fever. Prout men- 
tions inflammation and uneasiness about the external 
orifice of the urethra. 

Diabetes occurs under two distinct forms, viz: diabetes 
mellitus, and diabetes insipidus. Of the latter there 
are three varieties; 1. That in which the urine contains 
an excess of urea; 2. That in which the urine is albu- 
minous; and, 3. That in which it is surcharged with 
phosphates. 



196 



DIABETES. 



Diabetes Mellitus. In this variety, the urine is saccha* 
vine, of a pale straw color, sometimes approaching to 
a greenish hue ; its smell resembles that of milk. It 
always contains less urea than healthy urine. Prout, 
who restricts the term diabetes to this variety, says, that 
diuresis is not essential to the disease. 

A natural predisposition to diabetes exists in some indi- 
viduals. I have known three members, out of one fa- 
mily, die of this disease. 

Of the exciting causes, we know little or nothing. 

Proximate cause. The opinions on this head are ex- 
ceedingly various. Sydenham, Rollo, Cullen, and 
others, regard derangement of the digestive functions, 
and want of energy in the assimilative |powers, as the 
primary affection. Objections stated to this opinion. 
I regard diabetes, as a disease essentially and prima- 
rily located in the kidneys, — the stomach, lungs, skin, 
and in short the whole system, becoming secondarily 
affected. The sugar contained by the urine, is wholly 
the result of a morbid action of the kidneys, for the se- 
rum of the blood of diabetic patients, does not contain 
a particle of it, It would seem, that the urea which is 
secreted with the urine in health, is converted into su- 
gar in diabetes. The analogy between urea and sugar 
pointed out. Sugar contains just double the quantity 
of oxygen and carbon, and the same quantity of hy- 
drogen, as urea — this latter substance possessing, in 
addition, a large proportion of azote, of which sugar is 
destitute. As diabetic urine contains very little or no 
urea, we may regard the sugar it contains, as a deprav- 
ed secretion of urea. 

Prognosis. Diabetes mellitus, is an exceedingly obsti- 
nate and dangerous affection, the instances of recovery 
from it being comparatively very few. 

Treatment. Various and diametrically opposite plans 
of treatment, have been recommended. Bleeding has 
been used with success, by Watt. In recent cases of a 
phlogistic character, it is often beneficial ; not so in 



DIABETES. 199 

protracted cases, or where there is much exhaustion. 
Topical bleeding, sometimes useful. Opium holds a 
high rank, as a remedy in this disease. Feriar gave 
it in union with bark and uva ursi. Prout prefers the 
pulv. ipecac, compos. Opium, with carbonate of iron, 
has been used with much advantage in chronic cases, 
with much debility and nervous irritation. (Latham, 
Prout.) Sulphate of quinine, a useful article in such 
cases. Magnesia, strongly recommended by Dr. Trot- 
ter; I have known it to do some good. Emetics, used 
successfully, by Richter. Warm bath and frictions 
with the flesh brush, useful auxiliaries. Exclusive 
animal diet, is generally admitted, as decidedly the 
best kind of food in diabetes. Of late, Dr. Starkey has 
published some cases, from which it appears, that, con- 
trary to the generally received opinion, a vegetable 
diet is sometimes more beneficial, than one consisting 
principally, or wholly, of animal substances. He 
cured cases with a vegetable diet, and one drachm of 
phosphate of soda, three times daily. Other remedies 
have been recommended, such as: cuprum ammonia- 
cum ; alum in 9j. doses ; tincture of cantharides ; cam- 
phor ; hepatized ammonia ; phosphate of iron, &,c. 

Excessive diuresis, with an excess of urea. Urine 
generally pale ; reddening litmus, when first voided ; 
free from sediment, being prone to decomposition; and 
becoming alkaline. The desire to pass urine is fre- 
quent and urgent; the urine apt to be increased in 
quantity, by cold weather. The functions of the skin 
are natural ; the pulse remains unaffected ; no particu- 
lar thirst, or craving for food ; the bowels are in general 
regular. Persons of a thin and spare habit, about the 
middle period of life, most subject to it. 

Causes. Whatever debilitates the general system, and 
particularly the urinary organs, as masturbation. 

Treatment. Tonics, with alkaline remedies and opi- 
um. Mercury, in alterative doses ; purgatives. (Prout.) 

Excessive diuresis, with phosphatic salts in the 



200 DIABETES. 

urine. Symptoms. Great general irritability; dys- 
peptic phenomena; sometimes costiveness; at others, 
debilitating diarrhoea, the stools being very unnatural 
in appearance; pain and uneasiness in the loins; coun- 
tenance sallow and haggard. As the disease proceeds, 
great " languor, depression of spirits, coldness of the 
legs, complete anaphrodisia, supervene. The urine is 
pale, very prone to decomposition." (Prout.) The 
sediment consists chiefly of the phosphates. 

Causes. Injuries done to the back — excessive fatigue — 
depressing mental emotions — irritation about the neck 
of the bladder, by calculi, and other circumstances. 

Prognosis. The prognosis is in general unfavorable, 
particularly when resulting from injury of the back. 
(Prout.) 

Treatment. Opium is, according to the experience of 
Prout, the only remedy that can be employed with 
any particular advantage, to allay the excessive general 
irritability which prevails in this disease. Alter the 
morbid irritability has been allayed, tonics must be 
given in conjunction with the opium — such as the mi- 
neral acids, cinchona, iron, uva ursi, and bitters. A 
stimulating plaster to the back and loins will prove 
beneficial. A strong infusion of alchemilla arvensis, 
has been found useful. Hyoscyamus, with uva ursi, 
very serviceable, where the constitution is sound, and 
the irritation is confined to the urinary organs. The 
diet should be digestible, mild, and nutritious. (Prout.) 



INDIGESTION. 201 

CHAPTER XIX. 

INDIGESTION. 

Symptoms. Variable appetite — generally none; flatu- 
lence, distention, acid eructations, and colic pains, after 
eating. These symptoms characterize the slighter 
cases of the disease. By repeated errors in diet, or 
long continuance, it generally assumes a more aggra- 
vated form ; in which case the stools lose their natural 
appearance, becoming bilious, very fetid, sometimes 
of a very dark color, at others too light or greenish, — 
and often mixed with portions of undigested food ; the 
skin becomes sallow; the urine high colored, and sedi- 
mentous; diarrhoea, followed by constipation; griping; 
a sense of weight in the right hypochondrium ; tender- 
ness of the epigastrium ; a foul and clammy tongue ; de- 
bility, particularly after the operation of purges; gene- 
ral despondency and irritability of temper; emaciation; 
a haggard expression of the countenance; frequently 
uneasiness of lying on the left side, and at last inability 
to rest easily on either side; a shrivelled and dry state 
of the skin, in protracted cases ; great sensibility to low 
temperature, &,c. 

Causes. There are two conditions necessary for healthy 
digestion, viz : 1. The secretion of a due quantity of 
healthy gastric liquor; 2. A healthy tone of the mus- 
cular coat of the stomach. Whatever therefore de- 
ranges either of these two functions, impairs digestion. 
The remote causes which are capable of effecting these 
morbid changes, act either directly on the stomach, or 
indirectly through the medium of the general system. 
Of the former kind are rail kinds of substances capable 
of irritating the stomach — such as irritating and indi- 



203 INDIGESTION. 

gestible articles of diet; the habitual use of spirituous 
drinks; the excessive use of condiments, opium, and 
other narcotics; the immoderate use of very warm, or 
very cold drinks; chronic hepatic disease ; over-disten- 
tion of the siomahc, by food or drink — of all the 
causes of indigestion, this latter one is the most com- 
mon. The circumstance which most commonly gives 
rise to over-distention of the stomach, is rapid eating; 
high seasoning, and frequent variety of food is also a 
frequent cause of over-distention. Over-distention does 
injury, by weakening the muscular fibres of the sto- 
mach, and by irritating the nerves of this organ. — 
(Among the causes that affect the stomach, secondari- 
ly, through the general system, are: the depressing pas- 
sions; intense study; excessive venereal indulgence; 
and whatever debilitates the general system. 

Proximate cause. Irritation of the nerves of the sto- 
mach, and debility of its muscular fibres, either exist- 
ing singly or conjointly. In consequence of these con- 
ditions, the solvent gastric fluid becomes either de- 
praved in quality, or deficient in quantity; and the 
contents of the stomach are not adequately embraced, 
and propelled forwards to the pyloric extremity. 

Observations on the multifarious sympathetic effects of 
gastric irritation, from imperfectly digested food in the 
primse via?, and on the morbid effects which result from 
the absorption of imperfectly elaborated chyle into the 
circulation. 

Treat3iext. The treatment of indigestion is divided 
into dietetic and medicinal. In slight cases, a proper 
attention to diet, with the occasional use of mild aperi- 
ents, and a rigid avoidance of the exciting causes, will 
rarely fail to establish a cure. In all cases, whether 
simple or complicated, mild or violent, an undeviating 
attention to diet, is essential to the management of the 
disease. No particular direction in relation to the kind 
of diet, can be laid down, which is applicable to all 



INDIGESTION. 203 

Cases. Some dyspeptics feel relieved by articles of 
food, which are altogether intolerable to others. Ev- 
ery dyspeptic must learn, m a great mensure, from his 
own experience, what will, or will not, agree with him. 
The degree of violence of the disease, too, has an im- 
portant influence upon the power of the stomach, to 
bear particular kinds of food. What may be taken 
without inconvenience in the first periods, will general- 
ly become insupportable in the latter stages of the dis- 
ease. At first, when mere debility of the stomach 
exists, the more digestible kinds of animal food, are 
decidedly the best; but if the disease continues, until a 
high degree of irritation, or chronic phlogosis, exists 
in the mucous membrane of the digestive organs, ani- 
mal food is no longer proper — the disease then requir- 
ing the mildest articles of the farinacious kind. Ani- 
mal is undoubtedly more digestible than vegetable food ; 
and where the gastric irritation is not very considera- 
ble, it will very generally be taken with the least incon- 
venience. As a general rule, therefore, we may lay it 
down, as an established principle, that animal food is 
the most proper ; and of this, the most tender muscular 
parts are to be used. The flesh of old is in general 
more digestible than that of young animals. Mutton, 
and most kinds of game, are of easy digestion. Pork 
is generally difficult to digest, yet some dyspeptics 
bear it better than other meats. Acescent and oily 
articles are most difficult of digestion. Venison is 
perhaps the most digestible of all meat. New bread 
is of exceedingly difficult digestion. Simple roasting 
and boiling is the best mode of preparing meat for 
weak stomachs. All kinds of 'fried articles of food, are 
intolerable. Cheese, milk, cream, and butter, are ge- 
nerally oppressive. Spices and condiments should be 
taken very sparingly. Fresh vegetables are very gene- 
rally injurious, particularly, cabbage, peas, and beans. 
Of fruits, cucumbers, pears, melons, currants, are the 
most indigestible. The food should be taken chiefly 



204 INDIGESTION. 

in a solid state. Slow eating, and perfect mastication, 
are all-important observances for dyspeptics. Not 
much drink should be taken during meals, or soon 
after. Moderate portions of good brandy, answer well 
in slight cases, but are improper in the more aggravat- 
ed ones. Simplicity in diet is of the utmost impor- 
tance; and what is of equal, if not of still greater im- 
portance, is, to avoid over-distending the stomach. 
Medicinal treatment. In slight and recent cases, gentle 
emetics and aperients, to remove the irritating contents 
of the stomach and bowels, with the use of mild to- 
nics; alkalines when the eructations are acid, and an 
animal diet, will generally remove the disease. To re- 
lieve the gastric pains, small doses of opium may be 
occasionally used. When functional disease of the li- 
ver exists, alterative doses of blue pill, with the occa- 
sional exhibition of some gentle laxative, are of great 
utility. Care must be taken, however, not to continue 
the use of the mercury, until the general system becomes 
affected by it. General mercurial excitement, is always 
improper, in dyspepsia. The nitro-muriatic acid, will of- 
ten prove serviceable, as a local tonic, and by its action 
on the liver. When the gastric irritation has assumed 
the character of chronic inflammation, that is, when 
the epigastrium becomes tender to pressure, the pulse 
tense and irritated, the tongue red, &,c. tonics, emetics, 
animal food, and all stimulating remedies, are injurious. 
The diet must be of the lightest farinaceous kind; 
leeches, or blisters to the epigastrium, are often highly 
useful; the nitrate of potash, dissolved in some mucila- 
ginous fluid, the occasional use of fluid purgatives, and 
gentle diaphoretic drinks, with the use of very small 
doses of the blue pill, must be resorted to. In very 
protracted cases, attended with a broken down constitu- 
tion and general irritation, mercury is improper. 



JAUNDICE. 205 



ICTERUS JAUNDICE. 



Symptoms. Skin and eyes yellow ; faeces clay colored ; 
urine bilious, communicating a yellow stain; generally 
slight pyrexia; occasional pain (sometimes very violent) 
in the epigastrium; indigestion; languor, nausea; a 
sense of fulness in the stomach ; torpor of the bowels ; 
colic pains : drowsiness ; bitter taste ; debility, and in- 
disposition to mental exertion ; disturbed sleep, &,c. 

The fundamental affection is either an idiopathic or sym- 
pathetic derangement of the biliary organs, or of the 
duodenum, by which the bile is either obstructed in 
its passage into the intestines, or its secretion is sus- 
pended. 

The occasional causes are very various. The principal 
are: intemperance in the use of spirituous liquors; ir- 
ritating substances in the primse vise ; cold ; suppression 
of acute and chronic cutaneous eruptions ; acrid bile 
irritating the common duct; biliary concretions plug- 
ging up the duct ; violent anger ; injuries and concus- 
sion of the brain ; spasm of the duodenum, or of the 
common bile duct; induration and enlargement of the 
pancreas; grief; terror; constipation; viscid mucus 
clogging the orifice of the common duct; retained me- 
conium; indurated liver; and, in short, whatever is 
capable either of suspending the secretion of bile, or 
preventing its natural egress from the liver. When it 
depends on spasm or biliary concretions, the pain i^ 
occasionally very violent. 

Proximate cause. The external icteric phenomena, de- 
pend on the secretion of bilious matter into the sub-cu- 
ticular tissues, in consequence either of the resorptiqp 
of bile into the general circulation, or of the retention 
of its elements in the mass of the blood, in case of he- 
patic torpor. When this occurs, the general capillary 
system, and particularly the cutaneous capillaries, per- 
form the office of the liver vicariously, and free the 



206 JAUNDICE. 

blood of a portion of its superabundant biliary ele- 
ments, by depositing them into the skin, &c. 

Observations on the ratio symptomatum. 

Great wasting of the flesh, and dropsy, are common se- 
quellse of very protracted and obstinate cases. The 
jaundice of new-born infants, is generally transient, and 
of no particular moment. When it depends on chro- 
nic hepatic disease, it is seldom cured. In general, 
however, it is not a dangerous affection, though often 
of difficult removal. 

Treatment. The mode of treatment should of course 
be modified, according to the nature of the fundamen- 
tal hepatic affection. When there is fever, with symp- 
toms of local inflammation, bleeding and blistering, 
with mercurial purgatives, must be chiefly relied on. 
When spasm of the common duct may be presumed 
to be the primary cause, which is attended with violent 
pain, constant nausea, and frequent vomiting, opium, 
stramonium, hyoscyamus; emetics, in nauseating 
doses; valerian; assafcetida; infusion of chamomile; 
purgatives; the warm bath; emollient cataplasms, or 
fomentations to the epigastrium; anodyne frictions, and 
enemata. When torpor of the liver exists, as the fun- 
damental pathological condition, (in which case, there 
is little or no pain experienced,) calomel is the princi- 
pal remedy — it should be given in purgative doses. 
Benefit may also be derived from infusion of taraxa- 
cum; saponaria; alkalies; ammoniac; mercurial fric- 
tions on the right hypochondrium; antimonials; blis- 
ters and sinapisms on the region of the liver; and ac- 
tive purgatives. When biliary concretions exisi, as the 
cause of the disease, emetics; purgatives, the warm 
bath; electricity; opium; stramonium; hvoscyamus; 
alkaline remedies ; copious bleeding; nauseating doses 
of antimonials; are serviceable. Durande recommends 
a mixture of vitriolic ether and spirits of turpentine, in 
the proportion of two parts of the former, to one of the 
latter, in doses of twenty drops, four or five times daily, 



SCORBUTUS. 207 

as a valuable remedy. Guyton Morveau recommends 
a solution of the yoke of eggs, in vitriolic ether, as very* 
efficacious. 



SCORBUTUS. 

Symptoms. First stage. Unusual languor, and want 
of muscular energy; stiffness of the knees; depression 
of spirits; a pale, sallow, lead-colored, bloated coun- 
tenance; skin dry, and covered with livid spots and 
blotches; particularly on the thighs, legs, arms and ab- 
domen; oedema about the ancles; gums spongy, and 
apt to bleed on being touched; fetid breath; a disa- 
greeable putrid taste ; desire for fresh vegetables, and 
acids; the blood is black, thick, and dissolved, with a 
great abundance of serum ; pulse soft and weak. As 
the disease advances, other symptoms, which mark the 

Second stage, occur, viz: Stiffness of the joints; indura- 
tions of the muscles; pains in the thighs, back, loins, 
and particularly in the knees ; oppressed respiration ; 
colic pains ; sub-cutaneous extravasations of blood ; 
ulcers, — particularly on the calves of the legs, and 
thighs, with cedematous, flabby, and bloody edges, dis- 
charging dissolved blood and ichor; muddy and high 
colored urine; passive hemorrhages from the gums, 
nose, rectum, bladder, &,c; sloughing of the gums, the 
teeth becoming loose in their sockets ; re-opening of 
old and cicatrized sores ; brittleness of the bones ; syn- 
cope on the slightest motion. 

In the third stage, there is extreme debility; frequent 
syncope; great oppression of breathing; a cadaverous 
exhalation from the body; sometimes palsy of one or 
more extremities; emaciation; occasionally dropsy, 
jaundice, and finally extreme exhaustion, with an irri- 
tated pulse. 

Causes. Persons of a debilitated and phlegmatic habit 
of body, with a disposition to obesity, are most subject 
to the disease. The occasional causes are: innutritious 



*208 SCORBUTUS. 

diet, conjoined with fatiguing labor, and exposure to a 
damp and impure air; excessive and repeated he- 
morrhages; impure diet; anxiety of mind, with a se- 
dentary mode of life ; the habitual and intemperate use 
of spirituous liquor; the continued use of either exclu- 
sive vegetable, or much salt animal diet. A damp 
and impure air, is a powerful co-operative cause with 
vitiated, or exclusive salt animal food, &c. 

Proximate cause. A morbid process of sanguification, 
and a consequent morbid condition of the blood. 

Treatment. The first and most important of the treat- 
ment is the removal of the causes which have produced 
the disease. When it is the result of impure diet, and 
a vitiated and damp air, more wholesome food and air 
are necessary. When exclusive salt animal food is its 
cause, vegetable acids, and a vegetable diet are the ap- 
propriate remedies. If an exclusive vegetable, or fari- 
naceous diet, has given rise to it, animal food, with 
moderate exercise in the "open air, is to be prescribed. 
All sorts of fermented liquors; acid fruits; alkalescent 
plants ; pure fresh water ; cleanliness ; free ventilation ; 
are remedial in this disease. The vegetables which 
have been found most beneficial, are: scurvy-grass; 
garlic ; water-cress ; garden-cress ; the fruit of the cloud- 
berry; (Chamae-morus;) cabbage, in the form of sour 
Jcrout; cochlearia, &,c. 

SCROFULA. 

Scrofula may be divided into two periods,~or states — the 
one that peculiar diathesis, called the scrofulous habit; 
the other, the disease in its state of development and ac- 
tivity. The scrofulous habit, or predisposition, may be 
acquired from accidental causes, or from hereditary 
transmission. The scrofulous habit is characterized by 
the following circumstances ; a particular delicacy and 
languor of countenance; smooth, soft, and flaccid 
cheeks; a dull lead-colored circle around the mouth, 



SCROFULA. 2i)9 

with fine red lips; swollen upper lip; inflammation 
of the edges of the eye-lids— ^-particularly in children; 
weak digestive powers; scabby eruptions about the 
head; irregular state of the alvine discharges; slow 
growth of the body; aptitude to take cold, foc.^— 
This dormant state of the disease may continue for 
years, or pass off, under favorable circumstances. 
More generally, however, it becomes gradually deve- 
loped, under the influence of various exciting causes; 
the lymphatic glands along the neck, and other parts 
become enlarged; and by degrees pass into a state of 
slow inflammation, terminating in induration, or suppu* 
ration— the ulcers thus formed, discharge a thin:, milky* 
and somewhat viscid fluid, — are but little painful, and 
exceedingly slow in cicatrizing. The cicatrices are 
uneven, and irregular; the eyelids and conjunctiva be- 
come inflamed, as well as the mucous membrane of 
the nose, and bronchia. In a more advanced state of 
the disease, the salivary and thyroid glands* and the 
pancreas, and other glandular parts, enlarge; eruptions 
appear on the skin; emaciation ensues: the extremities 
of the long bones enlarge ; ulcerations occur, particu- 
larly in the cartilaginous and glandular structures; 
some of the bones become carious ; the large joints in- 
flame and suppurate; the spine becomes diseased; the 
nose, and palate, are destroyed by ulceration; in short, 
there is scarcely any part of the body, which is not 
sometimes the seat of its frightful ravages. The most 
common course of scrofula, however, is the formation 
of tubercles in the lungs, and consequent phthisis pul- 
monalisi 
Scrofula occurs more frequently in children, than in 
adults. The scrofulous habit is rarely formed after 
the period of manhood. The most common causes 
which produce this morbid habit, are: cold and atmo- 
spheric vicissitudes; indigestible and unwholesome 
food; excessive indulgence in eating; confinement and 
want of exercise; long exposure to a humid atmos* 

D* 



210 



SCROFULA. 



phere; mental disquietude; chronic irritation in the 
stomach and bowels, from worms and other causes; 
exposure to cold and humidity, during convalescence 
from various diseases, particularly measles, scarlatina, 
whooping cough ; in short, whatever permanently de- 
bilitates the system, more especially during childhood. 

Proximate cause. The scrofulous habit, consists proba- 
bly in constitutional, or acquired excess of irritability 
in the lymphatic system, in connexion with a weak con- 
dition of the assimilative powers. 

Treatment. To counteract the scrofulous habit, great 
care is required, to avoid the exciting causes. The 
integrity of the digestive, perspiratory, and hepatic 
functions, is to be maintained, and the tone of system 
supported. This is to be done, by the occasional use 
of mild aperients ; alterative doses of mercury ; warm 
clothing ; mild vegetable tonics ; exercise in the open 
air; a simple, but nutritious diet; sea-bathing; the tepid 
shower bath; dry frictions; alkalines, when gastric 
acidity prevails. When the disease is established, the 
same course of treatment is required, with additional 
remedies, varied according to existing circumstances, 
When the disease exists in the state of lymphatic glan- 
dular tumors, iodine, bathing with salt water, leeching, 
and emollient poultices are often beneficial. In this 
state, advantage may also be occasionally derived from 
the extracts of conium maculatum, dulcamara, hyoscy- 
anius, belladonna, and minute portions of muriate of 
mercury. In general, however, irritating applications 
are improper, so long as the tumours remain indolent. 
When scrofulous ulcerations exist, benefit may be de- 
rived from liquor potassee; the narcotic extracts just 
mentioned ; the muriatesof mercury, gold, barytes, lime ; 
ptisans from tussilagafafara; sarsapririlla; arctium 
lappa. I have seen more good done, by minute doses 
of muriate of mercury, and large ones of extract of 
conium, than by any other remedies. Farr speaks in 
the highest terms of the efficacy of large doses of the 
liquor potassre, and mercurial frictions used conjointly 



MENTAL DISEASES. 



CHAPTER XX, 



MENTAL DISEASES. 



The diseases of the mind may be divided into four 
classes, viz: mania, monomania, dementia, idiotism. 

1 . Mania. General derangement of the mind, cha" 
racterized by a rapid succession of incoherent 
ideas — delirium ; violent excitement of the pas- 
sions, expressed by great agitation ; cries, singing, 
menaces, and fury. 

2. Monomania. Partial insanity — the patient be-? 
ing insane on one particular subject only. This 
class comprehends a great many varieties, as no- 
stalgia, fanaticism, hypochondriasis, misanthropy, 
&c. 

3. Dementia. Imbecility of mind — the reasoning 
faculties being defective, and memory weak or 
obliterated. It occurs in very old people ; and af- 
ter diseases of the brain, as apoplexy, epilepsy, &,c. 

4. Idiotism. Defective intellectual development, 
amounting sometimes to a total absence of mind; 
and, in some instances, even to a destitution of the 
instinct, which leads to the gratification of the ani- 
mal appetites. 

General symptoms. Sensibility impaired ; appetite, de^ 
praved, null, or voracious ; constipation ; fever in mania, 
and in the beginning of monomania; skin dry, and of 
a yellowish brown color ; in women, suppressed or uv 
regular menstruation. 

Causes. Hereditary predisposition, has an important 
share in the aetiology of mental diseases Mental de^ 
rangement from hereditary predisposition, is generally 



212 MENTAL DISEASES. 

announced " by whimsicalities of disposition; certain 
singularities of character; caprice in taste and habits; 
peculiar and evilly intentioned conduct; little aptitude 
to the study of the exact sciences; and in unmethodical 
taste for the arts of display, and the pleasures of imagi- 
nation." 

Among the most common occasional causes of insanity, 
are: violent passions; intense application to one object; 
jealousy; excessive joy, sorrow, hatred, terror, or sur- 
prise; religious enthusiasm; unrestrained imagination; 
poverty; excessive ill treatment; disappointed love, 
ambition, vanity ; mortified pride ; chagrin ; the crisis 
of female life, suppression of habitual discharges; re- 
percussion of chronic cutaneous affections; drunken- 
ness; parturition; pregnancy; epilepsy ; blows or falls 
on the head; acute and chronic diseases. 

Development, Progress, and Termination of Insanity. 
The development of insanity, in its incipient stage, is 
generally marked by a change in the habits, tastes, at- 
tachments, and passions of the patient. As the mental 
disorder advances, vigilance, head-ache, loquacity, or 
taciturnity; inconsistency in conduct; wild and ruinous 
enterprises; a neglect of the ordinary occupations; un- 
usual prodigality; inconsistent conduct; incoherence of 
ideas; and, finally, fixed monomanic hallucination, de-» 
lirium, or general aberration of the perceptive and rea- 
soning faculties. 

Insanity is sometimes periodical — at others, it is tempo- 
rary — passing off either spontaneously, or in conse- 
quence of remediate treatment; sometimes, it assumes 
a fixed and incurable state. Chronic, or incurable 
mania, or monomania, frequently terminates in de- 
mentation. (Georget.) Idiotism is always iucurable. 
Dementia is usually preceded or followed by paralysis. 

Prognosis. Recovery occurs most frequently between 
the ages of 'jventy and thirty. It seldom terminates 
favorably aller the fiftieth year of age. When insanity 
is connected with paralysis, or epilepsy, it may be re-. 



MENTAL DISEASES. 213 

garded as incurable. A recovery of the general health 
of the system, without a corresponding melioration of 
the mental hallucination, is an unfavorable sign. It 
has been observed, that cold is more favorable to re- 
covery, than warm weather. 

Pathology of Insanity, Many pathologists contend, that 
the mind is never deranged idiopathically ; but always 
in consequence of some physical disorder, whether 
functional or organic, of the animal system. To this 
opinion, 1 am myself inclined to give my assent. This 
subject is fully discussed in the lectures. 

Treatment. The treatment is divided into moral and 
remedial management Under the head of moral 
treatment, are: a soothing, mild, and conciliatory ma- 
nagement; the absence of all coercive measures, unless 
imperiously demanded by the violence of the maniacal 
fury, or attempts to injure themselves or others ; a sepa- 
ration of the patient from all objects calculated to recal 
the sentiments, or passions, which gave rise to the dis- 
ease; a judicious diversion of the mind, from the ob- 
jects upon which the thoughts are habitually directed, 
and an encouragement to reflection "upon subjects of 
personal conduct and thought." To restrain and sub- 
due the turbulent, it is often sufficient to envelope the 
head suddenly with a cloth, so as to prevent them from 
seeing. The most furious generally become calm, so 
soon as they are thus prevented from seeing. The 
false ideas and fancies of insane persons, should never 
be encouraged, nor vehemently contradicted. By 
watching favorable opportunities, circumstances will 
generally occur, which, by a few judicious remarks, 
may lead them to doubt of the correctness of their no- 
tions ; " and doubt of the correctness of their own per- 
ceptions, marks the period for persuasion and convic- 
tion of error." 

Convalescents from insanity, should be suffered to asso- 
ciate freely with each other; nothing, says Georget, 
promotes recovery more than such an intercourse. 



214 VERMINOUS DISEASES. 

Mechanical employments are often of great benefit in 
the management of lunatics. 
Remedial management. The remedies most efficacious, 
are: blood-letting, where there is much arterial excite- 
ment ; purging ; blisters ; the cold shower bath ; frictions ; 
tepid bath; mild and digestible diet; enemata. 

VERMIMOUS DISEASES. 

Various opinions concerning the origin and formation of 
worms, in the intestinal canal. It does not appear that 
they are received from without, because they are never 
found out of the animal body; and when removed out of 
the body, they speedily die ; and, lastly, earth worms, 
and such as live in water, do not change their forms, 
when received into the intestinal canal. There are 
five varieties of intestinal worms. 

1. Tricocephalus dispar. These worms are from 
an inch and a half, to two inches in length. About 
two thirds of their length is almost as thin as a 
horse hair, the remaining and posterior part being 
considerably thicker, and terminating in a rounded 
extremity. They are found principally in the 
cteenm. They are seldom numerous. 

2. Ascaris vermicularis, (oxyitris vermictdaris,) 
These are exceedingly short — not more than two 
lines in length, very thin and white. Their usual 
seat is in the rectum. 

3. Ascaris lumbricoides.. These worms are from 
two or three, to ten or twelve inches in length, 
round, of yellowish white, or brownish red color, 
of nearly a uniform thickness, except at the extre- 
mities, which taper to a blunt point. They are 
from two to three lines in thickness. They inha- 
bit the small intestines chiefly; but occasionally 
ascend into the stomach. 

4. Ttenia lata, (Jwthricoceplialus latus.) This 
worm often acquires a very great length — from 



VERMINOUS DISEASES; 21 5 

twenty to thirty feet and more ; it is from four to 
six lines in breadth, flat and white, resembling a 
piece of white tape, and composed of a series of 
concatenated joints. It inhabits the upper por- 
tion of the bowels and the stomach. The head is 
armed with two processes, by which the worm 
attaches itself to the intestines. 
5. Taenia solium, ( T. Cucurbitina.) This worm 
is rarely, if ever, voided whole; it generally passes 
offin short joints, resembling, in some measure, 
the seeds of gourd. Pieces, however, upwards 
of twenty feet, of this worm, have been voided. 
The head is small, and furnished with four small 
apertures. (Oscula.) It inhabits the small intes- 
tines chiefly. 
Symptoms. Countenance pale, lead-colored, with occa- 
sional transient flushes; eyes dull; pupils dilated, with 
a bluish semicircle around the lower eye-lids; tickling 
in the nose; tumid upper lip; occasional head-ache, 
and humming in the ears; copious secretion of saliva; 
tongue slimy or furred ; breath foul ; variable appetite — 
being sometimes voracious — at others wholly gone; 
transient pains in the stomach ; occasional nausea and 
vomiting; pains in the abdomen — particularly about 
the umbilical region ; frequent slimy stools, or costive- ' 
ness ; urine turbid, yellowish, or milky ; abdomen tumid! 
and hard, with emaciation of the other parts of th£ 
body ; lassitude ; irritability of temper. None of these 
symptoms, however, are certain indications of the exis| 
tence of worms in the bowels — the only certain indica* 
tion being the appearance of them in the evacuations 
from the bowels or stomach. 
The opinion which is expressed by some, that worms /are 
harmless in the intestinal canal, is without foundation. 
It is nevertheless probable, that that peculiar condition 
of the alimentary canal, which favors the production of 
worms, is more frequently the cause of mischief, tnan 
the worms themselves. Worms give rise to a variety 



216 VERMINOUS DISEASES. 

of affections, such as chorea, epilepsy; hydrocephalus j 
emaciation; convulsions ; paralysis, and a vast variety 
of anomalous disorders. 

Treatment. In prescribing for the removal or destruc- 
tion of worms, it is of some consequence to confine the 
patient to a spare and liquid diet, and to exhibit two or 
three mild cathartics a few days previous to the exhi- 
bition of the proper anthelmintic remedies. With 
these preparatory measures, the ordinary vermifuge re- 
medies will disappoint us much more seldom than 
without them. My own plan of treatment for the ex- 
pulsion of the lumbricoidcs, is to put the patient on a 
liquid diet, and to give a small dose of Epsom salts 
every morning, for three days in succession. On the 
fourth morning, 1 order a decoction of the root of spi- 
gelia, in the proportion of an ounce of the root to one 
pint, of water, and boiled down to half a pint. This 
being sweetened, is to be drunk in the course of three 
or four hours; and immediately after the whole of the 
decoction is taken, an active dose of calomel and jalap 
— or what is perhaps still better, castor oil and turpen- 
tine, is to be taken. I have rarely failed, by this me- 
thod, of removing worms, where they existed. The 
most efficacious anthelmintics, for the destruction of 
ascarides Iumbricotd.es, besides spigelia, which I regard 
as decidedly the best, are: sem. santonici; chenepodi- 
um anthelminticum, dolichos pruriens; calomel, garlic, 
conferva helminthcordon, and geoffrea surinamensis. 

The removal of ascarides, is often exceedingly difficult 
Remedies employed in the form of enemata, are gene- 
rally more efficacious, than when given by the mouth. 
My usual prescription for the expulsion of these worms, 
is to exhibit three or four aloetic purges every second 
day, together with two or three enemata, composed of 
a solution of common salt daily. Injections of a solu- 
tion of aloes — of lime water, or of infusions of any of 
the ordinary anthelmintics, will occasionally bring 
away these troublesome little worms. I have, in a few 



VERMINOUS DISEASES, 21 f 

instances, brought them away in great quantities, by np 
jections composed of spirits of turpentine, mixed with 
milk. The introduction of a bougie, smeared over with 
mercurial ointment, has been employed effectually 
against these worms. JN ils Rosen speaks very favora- 
bly of injections compsed of a drachm of refined su- 
gar, dissolved in warm milk. 

For the expulsion of the tape-worm, a great variety of 
remedies and modes of treatment have been recom- 
mended. The anthelmintics that have been found 
most efficacious against this species of intestinal worm* 
are: polypodium filix mas; spirit of turpentine; tin; 
valerian, and the bark of the pomegranate root. The 
latter article has been particularly recommended of* 
late years, as a powerful remedy against the tapeworm. 
Whatever mode of treatment be adopted, it is always 
of much consequence to prepare the patient, by diet and 
laxatives, before the proper vermifuges are given. A 
spare and liquid diet, with the daily use of small doses 
of saline purgatives, for five or six days, will greatly in- 
crease the chance of procuring the expulsion of the 
worm, by the use of anthelmintics. The following ig 
the substance of some of the most celebrated methods of 
treatment recommended for the removal of this worm* 

Alston's method. An active purge; next morning, one 
ounce of pure tin filings; on the second, third, and 
fourth mornings, half an ounce of the same metal, fol- 
lowed, on the fifth morning, by an active purge. Des- 
saulVs method: mercurial frictions on the abdomen* 
followed by a drastic mercurial purge. Heren* 
schwand?s method: one drachm of powdered male fern 
root, mornings and evenings, on an empty stomach, for 
two days in succession; on the morning of the third 
day, take the following: R. G. Gambog. gr. xij. Sub- 
carbonate potass, gr. xxx. Sapon Venet. gr. ij. Misce. 
Three hours after this, an ounce of ol. ricini. is to be 
taken. Hufeland's method: a cup of a decoction of 
garlic in milk, every morning, on an empty stomach* 

E* 



218 



VERMINOUS DISEASES. 



with a table-spoonful of castor oil every morning, noon, 
and evening, half an ounce of the filings of tin, once 
daily, and frictions with petroleum, on the abdomen. 
This must be continued for several weeks. 
Spirits of turpentine, has been employed with much 
success for the expulsion of taenia. From two to three 
ounces of this article, should be given at once; and 
followed, in two hours, by a dose of castor oil. The 
bark of the pomegranate root, has been recently strong- 
ly recommended, for the removal of taenia. 



FINIS. 



347 7 



